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Wellness Screening

Total

0-40: Fairly healthy; 40-60: Some hormonal imbalance is likely; 60 or more: Deficiency is probable

Top 5 Main Concerns:

I hereby consent to Dr Chang or his office staff to draw my blood for testing. I understand that blood draw may lead to bruising, swelling, discomfort, bleeding at the site of blood draw. Results from my lab work will be reviewed over the phone or may be left on voicemail.

19500 Sandridge Way, Suite 350 • Lansdowne, VA 20176 • Phone 703-729-5553 • Fax 703-729-1694 • www.gotobeauty.com

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