Chlamydia, Gonorrhea & Trich Test

Testing Consent Form

By [clicking Accept below], I request and hereby authorize Clinical Enterprise, Inc., d/b/a EmpowerDx or one of its affiliated clinical laboratories (“CEI”) to conduct laboratory testing for (i) sexually transmitted infection (“STI”); (ii) genetic testing; and/or (iii) general wellness testing as I have selected and ordered on https://www.thehealthhub.com/us/ (the “Site”). I have reviewed written information about my chosen test or tests, including the nature and reliability of a positive or negative result, and I have been given an opportunity to ask questions. I have been informed of the availability and importance of genetic counseling and given access to information about how to obtain such counseling. I also understand and agree that:

1. I am responsible for the collection of my specimen using the collection supplies provided to me by CEI.

2. The STI test and genetic testing requires a swab sample. The swab may be uncomfortable, painful and it may cause a mild abrasion or bleeding. No long-lasting side effects from the swab sample are expected, and the slight discomfort is temporary.

3. The general wellness testing requires a finger prick. The risks and complications of a finger prick include the following: pain at the finger prick site, bruising, lightheadedness, inflammation around the finger prick site and rarely, infection.

4. It is possible that I may collect a sample that is inadequate for testing or that gets contaminated in the collection process and if that happens, I will be asked to collect a new sample. In rare occasions, errors may occur during the testing process and there is a possibility that a test may not work properly. If this happens, I may be asked for an additional sample.

5. Genetic tests cannot detect all genetic mutations and all carriers of a condition. It is possible that I am a carrier of an uncommon genetic mutation that cannot be detected by my selected genetic test.

6. This test is entirely voluntary. The best way to learn about alternatives to my chosen testing is to discuss alternatives with a qualified health care provider.

7. I have voluntarily provided relevant family medical history to the best of my knowledge.

8. I understand that a genetic test may detect previously undisclosed non-paternity or that it may reveal a medical condition in another family member.

9. A negative test result does not guarantee my health or the health of other family members.

10. My test results will be available through CEI’s EmpowerDX Patient Portal.

11. This testing and the results are not a substitute for medical advice or treatment from a qualified health care provider. If I test positive for an STI, I will be offered a telemedicine consultation with a health care provider to review my results as part of the cost of the test. If I wish to use this service, my results will be shared with a third party telemedicine provider. If I do not wish to use this service, I understand that it is important for me to promptly obtain care from a qualified health care provider.

12. CEI and its affiliated laboratories are required by law to report certain infectious disease test results, including STI test results.