The subscriber confirms that they have read the Disclosures, Disclaimers, and Important Information section.
The subscriber confirms that they understand the issues discussed in the above-mentioned section.
CONSENT AND CHOICES
The subscriber hereby gives his/her consent (on their behalf or on behalf of a minor or person who is incapable of providing consent whom they are an attorney for) for the following:
Content of Report (choose one):
I request that my pharmacogenetic report display ONLY recommendations for medications within the medication category requested, OR
I request that my pharmacogenetic report display recommendations for ALL the drugs tested.
Genetic Information (choose one):
I request that my pharmacogenetic report show NO genetic information (Drug Recommendations only), OR
I request that my pharmacogenetic report show BOTH my genetic information and my Drug Recommendations.
Access to Results (choose one):
I request that ONLY the healthcare professional (doctor/pharmacist) whose information I provided to Personalized Prescribing Inc. be granted access to view my pharmacogenetic report, OR
I request that BOTH I AND the healthcare professional (doctor/pharmacist) whose information I provided to Personalized Prescribing Inc. be granted access to view my pharmacogenetic report.
I request that ONLY I be granted access to view my results.
I understand that only a healthcare professional may interpret and utilize the report to improve my health outcome. I understand that I should never make any changes to my medication without first consulting my healthcare professional.
I consent to taking a pharmacogenetic test, provided by Personalized Prescribing Inc.
I consent to providing Personalized Prescribing Inc. with personal information, including portions or all of my medical history.
I consent to Personalized Prescribing Inc. assigning me a barcode for the purpose of removing my personal health information – including my name – from my DNA sample and genetic information.
I consent to providing Personalized Prescribing Inc. with a barcoded sample of my DNA, which will be collected by me or by my doctor, and which will be sent through the Canadian postage system to our genetic laboratory in Ontario.
I authorize Personalized Prescribing Inc., a CLIA-certified genetic laboratory, to determine my genetic information from my DNA sample.
I authorize Personalized Prescribing Inc. to determine drug recommendations based on my genetic information.
I authorize Personalized Prescribing Inc. to store my DNA sample for 90 days or until the next internal proficiency testing date, whichever case is longer, in case additional testing is necessary.
I authorize Personalized Prescribing Inc. to archive a digital file of my barcoded (anonymous) genetic information within their encrypted and firewalled database system for 25 years, according to regulations and recommendations from international accreditors CLIA (Clinical Laboratory Improvement Amendments) and CAP (College of American Pathologists), respectively.
I authorize Personalized Prescribing Inc. preparing a pharmacogenetic report based on my genetic information that contains my name, my barcode number, and my drug recommendations and/or my genetic information, depending on my choices provided in this informed consent document.
I understand that, as in all testing, there is a possibility of delay or error.
I agree to release Personalized Prescribing Inc., my employer, and their representatives from liability for injury that may arise from collecting and testing my DNA sample, and from any effects or actions that the results of this test may have on me or any other individual.
I agree that I have read and understood all the information presented in this document and have been given the opportunity to ask questions and have had my questions answered.
To requisition your P3 test, fill out the form below.
Once you have read through this important information, you may download the requisition form below. Please fully read, understand, and sign the form before you email it to firstname.lastname@example.org or fax to (416) 863 – 5157. Both methods are 100% confidential.