Informed Consent and Choices

RIGHT DRUG. RIGHT DOSE. RIGHT PERSON.

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 drug compatibility 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 drug compatibility 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 drug compatibility 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.

The above mentioned information is repeated in the Informed Consent Form (available for download below as well as after ordering your drug compatibility test at checkout).

Please note this form is mandatory for purchasers of the drug compatibility test only. Please fully read, understand, and sign the form before you email it to info@personalizedprescribing.com or fax to (416) 863–5157. Both methods are 100% confidential.