Authorization and Consent for Diagnostic Testing
I voluntarily consent and authorize TOXN Inc., including its third-party service providers, to perform the collection, testing, and analysis of my hair sample for the purposes of routine laboratory testing. I understand that there are risks, benefits, and alternatives associated with undergoing routine laboratory testing. Risks may include discomfort during and after the hair collection or false positive or false negative test results. Benefits may include helping my primary care provider or other qualified healthcare provider identify medical problems, symptoms, or conditions to provide me with treatment guidance. Alternatives to this testing include not obtaining laboratory testing or using other testing methods. Critical or abnormal results will be flagged in the testing results. I assume responsibility to take appropriate action with regard to my test results by consulting my primary care provider or other qualified healthcare provider. Should I have questions or concerns regarding my results, or a worsening of my medical condition, I will promptly seek advice and treatment from my primary care provider or other qualified healthcare provider. I further acknowledge:
- I am the individual who will provide the hair sample for the test(s) that I am requesting.
- I am at least eighteen (18) years of age.
- I have read and understand the information provided about the test(s) on the website where I requested the test.
- The information I have provided is correct to the best of my knowledge. I will not hold TOXN, Inc. or their employees or agents responsible for any errors or omissions resulting from such information.
- My health information and results may be shared with TOXN, Inc., its third-party service providers, employees, and agents for the purpose of ordering, processing, and reporting my results.
- Services provided by TOXN, Inc. are purely informational, do not create a physician-patient relationship, and do not constitute medical advice, care, or diagnosis or treatment of any medical condition, disease, or illness.
- I authorize TOXN, Inc. and its third-party service providers to contact me via email or text message to communicate with me regarding my test. I understand that emailing and text messaging is not a secure means of communication and that my information may be accessed by an unauthorized third-party.
Patient Rights and Privacy Practices
- Privacy Policy: TOXN, Inc. may use and disclose your information as described in our Privacy Policy, at www.toxn.ai/privacy-policy
- Disclosure of personal information: I acknowledge that my test results and associated information may be disclosed to third-party service providers that facilitate the service, as well as to accredited labs, healthcare providers, and appropriate county, state, or other governmental and regulatory entities and others as described in our Privacy Policy, at www.toxn.ai/privacy-policy.
Release
- To the fullest extent permitted by law, I hereby release, discharge and hold harmless TOXN, Inc., including, without limitation, any of its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my diagnostic test or the disclosure of my test results.
- I acknowledge and agree that I have read this form and understand and agree to the statements contained within it. I voluntarily consent to proceed with the laboratory tests described in this form.