RIGHT DRUG. RIGHT DOSE. RIGHT PERSON.
Before ordering your Rx Report® – Psychiatry Test, it is crucial that you read and fully understand both the Disclosures, Disclaimers, and Important Information section, and this section below on Informed Consent and Choices.
When you have read and fully understood all the concepts in these sections, you may order your Rx Report® – Psychiatry Test and fill out the Informed Consent form that will be available for download after purchase on the “Thank You” page. You may also download the form from the bottom of this page.
You must fill in and sign your Informed Consent form before your Rx Report® – Psychiatry Test sample kit is shipped to you.
If you have any questions about any of the information below, please call us at 1 (844) 943-0210 or email info@personalizedprescribing.com. Both methods are 100% confidential.
Informed 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:
Access to Results (choose one):
- I request that the healthcare professional (doctor/pharmacist) whose information I provided to Personalized Prescribing Inc. be granted access to view my Rx Report® – Psychiatry report, OR
- 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 Rx Report® – Psychiatry 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 Personalized Prescribing Laboratory in Richmond Hill, Ontario, Canada.
I authorize Personalized Prescribing Laboratory, a certified genetic laboratory, to determine my genetic information from my DNA sample.
I authorize Personalized Prescribing Laboratory to provide Personalized Prescribing Inc. with my genetic information for the purpose of providing drug recommendations based on the information.
I authorize Personalized Prescribing Laboratory 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 Laboratory 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. to prepare a Rx Report® – Psychiatry 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 understand that I can direct that my genetic information at Personalized Prescribing Inc. be destroyed, and that they will comply within a week of receiving my direction.
I agree to release Personalized Prescribing Inc., Personalized Prescribing Laboratory, 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.
