Testing Consent Form
I authorize specimen collection with a nasopharyngeal swab, nasal swab, saliva, urine and/or collection of blood through venipuncture for testing. I further understand, agree, certify, and authorize the following:
- I understand that HALED LLC (“Haled”), has contracted with IMS A Medical and Paramedical Service Company (“IMS”) and MediPro Direct (“MPD”) for collection of my specimen. I authorize IMS and MPD to collect the specimen.
- I have the right to refuse testing. In the event I refuse testing, Haled will not be obligated to make any refunds. It will be at discretion to decide if a refund is issued, including the refund amount.
- Specimen collection methods may be uncomfortable, painful, or potentially cause mild abrasion or bleeding. No long-lasting side effects from testing are expected. I understand that there is minimal risk with collection of a specimen with a nasal swab. I acknowledge that the nature of the collection may cause slight discomfort.
- I understand that risks and complications of specimen collection obtained via blood draw include: pain at the draw entry and draw site, bruising, lightheadedness, inflammation of the vein, rare risk of infection and rare risk of nerve or tendon injury.
- has contracted with third party laboratories that are compliant with applicable regulations under the Clinical Laboratory Improvement Amendments of 1988 (“CLIA”) for laboratory analysis and report of my specimen. I authorize such CLIA-compliant laboratories to perform testing on my specimen. A list of CLIA complaint laboratories can be requested by emailing customer service at firstname.lastname@example.org.
- I understand that processing of my specimen and results may take between 5 to 7 days.
- I authorize CLIA-compliant laboratories to release test results or other information relevant to my test results to and to me.
- I understand that has infectious disease reporting responsibilities under applicable governmental regulations and will report my testing information in accordance with these regulations.
- I understand and agree that I will not make any changes in my medication regimen without consulting a physician for any of the tests offered by Haled.
- I agree that none of the tests offered by are intended to diagnose any condition, medical or otherwise. Only a healthcare provider can diagnose or make determinations regarding diagnosis of a medical condition. I also understand and agree that none of the tests offered by Haled are a substitute for seeking professional medical advice, help, diagnosis, or treatment.
- I understand that all tests purchased through are ordered by a licensed healthcare professional authorized to order laboratory testing in accordance with applicable state laws.
- I understand that at the time I order a test through Haled, I am 18 years of age or older. I understand that if I am under the age of 18, permission from a legal guardian 18 years of age or older is required.
- I understand that I am not entering into a doctor-patient relationship with , or any ordering physician or physician group, and that any questions or required follow up related to my test results shall be my responsibility to arrange with my own physician.
By clicking I agree, I acknowledge and agree that I have read, understand, agree, certify, and authorize the information above and further agree that I, along with my heirs, executors and assigns, hereby release , each CLIA-compliant laboratories, any ordering physician or physician group, IMS, and MPD, including each of their respective employees, agents, and contractors from any and all liability and claims arising from or related to my specimen collection or testing.