Good Hearts Testing, LLC Diagnostic Testing Consent and Release Form

Good Hearts Testing, LLC

Mobile Diagnostic Testing: Informed Consent and Release

Please carefully read and sign the following Informed Consent and Release:

• I authorize this Mobile testing service to conduct collection and testing through a nasopharyngeal swab, oropharyngeal swab, urine collection, self-administered vaginal swabs, or blood draw, as ordered by an authorized medical provider or public health official.
• I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be requested or required by law.
• I understand the risks associated with mobile laboratory testing which include but are not limited to bleeding, infection, and pain associated with the procedures required for specimen collection.
• I authorize Good Hearts Testing, LLC to provide my with a copy of my diagnostic testing results via HIPAA compliant email or telephone communication using the information provided in my booking. Furthermore I certify that I have verified the information provided in my booking and attest that m y contact has been reviewed and is correct.
• I understand the testing service is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.
• I understand that, as with any medical test, there is the potential for a false positive or false negative results.
• Refund Policy: By signing below I certify that I have read and agree to the refund policy outlined on Good Hearts Testing, LLC’s website (www.GoodHeartsHealth.com) under the FAQ section. Refunds will only be issued for canceled tests prior to specimen collection

I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks of the procedure. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for diagnostic laboratory testing.

RELEASE OF LIABILITY AND WAIVER OF RIGHTS:

I, the undersigned, accept that services might be rendered in a non-private setting. Furthermore, I hereby release and forever discharge for myself, my heirs, executors, administrators and assignees Good Hearts Testing, LLC and their employees, owners and representatives from any and all claims, demands, actions and causes of action, which may result from participation in this testing.