1) Authorization and Consent for Diagnostic Testing
a) I voluntarily consent and authorize Cynergy Wellness Inc. to review the collection, testing, and analysis for the purposes of a diagnostic test. I understand that there are risks and benefits associated with undergoing diagnostic testing and there may be a potential for false positive or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have questions or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider. I further acknowledge the following:
i) I am the individual who will provide the sample for the Test(s) that I am requesting or I am the parent or legal guardian of a minor who is providing the sample for testing.
ii) I am at least eighteen (18) years of age or I am the parent or legal guardian of a minor who is providing the sample for testing.
iii) I have read and understand the information provided about the Test(s) that I have been provided on the website where I requested the Test.
iv) The information I have provided in connection with the Cynergy Wellness Inc. is correct to the best of my knowledge. I will not hold Cynergy Wellness Inc. or its health care providers responsible for any errors or omissions that I may have made in providing such information.
v) My health information and results may be shared with Cynergy Wellness Inc. providers, including physicians and administrative agents for purposes of providing care to me.
vi) Services provided by Cynergy Wellness Inc. does not constitute diagnosis or treatment of any condition, disease, or illness.
vii) I authorize Cynergy Wellness to contact me via text message to communicate with
me regarding my test.
2) Patient Rights and Privacy Practices
a) Notice of Privacy Practices and Patient Rights: Cynergy Wellness Inc. Notice of Privacy Practices describes how it may use and disclose your protected health information for other purposes that are permitted or required by law. To review a copy of Cynergy Wellness Inc. Notice of Privacy Practices, go to www.CynergyWellness.com.
b) Disclosure to Government Authorities: I acknowledge and agree that my test results and associated information may be disclosed to appropriate county, state, or other governmental and regulatory entities as may be permitted by law.
3) Release
a) To the fullest extent permitted by law, I hereby release, discharge and hold harmless, Cynergy Wellness Inc., including, without limitation, any 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.
b) By selecting the ACKNOWLEDGEMENT during the registration process for diagnostic testing, I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I have read the contents of this form in its entirety and voluntarily consent to proceed.
cynergywellness.com | [email protected] | (844) 800-6767
