Informed Consent Form

Before ordering your RxReport™, 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 RxReport 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 and sign your Informed Consent form before your RxReport™ 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:

Content of Report (choose one):
checkbox for webI request that my Pharmacogenomic report display ONLY recommendations for medications within the medication category requested, OR
checkbox for webI request that my Pharmacogenomic report display recommendations for ALL the drugs tested.

Genetic Information (choose one):
checkbox for web I request that my Pharmacogenomic report show NO genetic information (Drug Recommendations only), OR
checkbox for web I request that my Pharmacogenomic report show BOTH my genetic information and my Drug Recommendations.

Access to Results (choose one):
checkbox for web I request that ONLY the healthcare professional (doctor/pharmacist) whose information I provided to Personalized Prescribing Inc. be granted access to view my Pharmacogenomic report, OR
checkbox for web 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 Pharmacogenomic report.
checkbox for web 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 Pharmacogenomic 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 Inc. in Quebec.

I authorize Personalized Prescribing Inc., a certified genetic laboratory, to determine my genetic information from my DNA sample.

I authorize Personalized Prescribing Inc. to provide Personalized Prescribing Inc. with my genetic information for the purpose of providing drug recommendations based on the 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 Pharmacogenomic 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., 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 RxReport™ at checkout).

Please note this form is mandatory for purchasers of the RxReport™ 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.

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