Authorization for Release of Information Guest Name(Required) First Last Email(Required) Phone(Required)Guest Birth Date(Required) MM slash DD slash YYYY Session Date(Required) MM slash DD slash YYYY Welcome and thank you for participating in the Blood Marker Program provided by Dr. Reza Danesh, M.D. In order to ensure a seamless Guest experience, Dr. Danesh will provide Sensei Wellness Holdings, Inc (“Sensei”) information regarding your lipid profile, specifically your Hemoglobin A1C, Blood Glucose Levels, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglyceride levels. As Sensei is not a medical care provider, Dr. Danesh will not share any medical diagnosis information with Sensei nor will Sensei provide any medical diagnoses. This information will be provided by Dr. Danesh to Sensei’s Retreat at Sensei Lanai, A Four Seasons Resort, One Keomoku Highway, Lanai City, HI 96763 via. This information will be securely stored in Sensei’s systems once provided to Sensei. This information will only be used to provide you with recommendations to improve your lifestyle and will not be used for any other reason. For more information, please reference Sensei’s Retreats Privacy Policy available at sensei.com/privacy-policy-retreats. While this authorization will only apply to this session, you have the right to revoke this authorization at any time by providing Dr. Danesh with a written notice. You also understand that your revocation will NOT affect any disclosures that occurred before your written revocation. If you do not revoke this authorization, the authorization will expire at the end of your Stay. By checking the box below, you authorize Dr. Danesh to share with Sensei the information described in Section 1. This authorization is voluntary.(Required) I Agree
