1- Client Intake Form
I hereby grant permission to Stamated LLC dba Accurate Diagnostics to perform testing or specimen collection for the purpose of conducting certain screening test(s), which may require venipuncture, finger stick, nasal swab or oral fluid collection, as set forth above at my direction. I understand that the actual testing may be performed by Stamated LLC dba Accurate Diagnostics or a third-party laboratory.
I understand that the tests requested are for my own use and not for medical diagnostic or treatment purposes. I agree that I am personally financially responsible for payment of fees for all tests ordered and collected by Stamated LLC dba Accurate Diagnostics at my request, and I agree will not seek to be reimbursed by Medicare, Medicaid or any other government insurer/payor for the test(s) performed.
I understand that test results reported by Stamated LLC dba Accurate Diagnostics will be reported directly to me in the manner I have chosen above, and I understand that it is my sole responsibility to consult my own medical professional for the interpretation, analysis, evaluation, and explanation of my test results in my discretion.
I understand that if testing returns critical values which may indicate a serious medical condition, Stamated LLC dba Accurate Diagnostics or a representative thereof will make reasonable attempts to notify me promptly, including by telephone and/or email. I also understand that it is my responsibility to ensure that my contact information is accurate and to notify ARCpoint Labs of any changes.
I agree that Stamated LLC dba Accurate Diagnostics, directors, staff, physicians, and/or any agent or employees thereof (“Stamated LLC dba Accurate Diagnostics”) shall not be liable for any claim arising out of or related to the Services, including but not limited to, inaccurate, uninterpreted, misinterpreted results or results not received and do hereby expressly forever release and discharge Stamated LLC dba Accurate Diagnostics from such claims, demands, injuries, damage, or causes of action.
I HEREBY CERTIFY THAT I HAVE READ THE ABOVE ACKNOWLEDGEMENT AND HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENTS. BY SIGNING BELOW, I CONSENT TO UNDERGO THE COLLECTION AND LABORATORY TESTING UNDER THE CONDITIONS SET FORTH HEREIN.
Electronic Signature Agreement: You acknowledge that you have read the terms above and by checking the "I agree" box below, you are accepting this as your consent to have the requested test administered. *
2 - Authorization to Email My Test Results
I, the undersigned, authorize Stamated LLC dba Accurate Diagnostics to provide my laboratory results directly to me at the e-mail address I have provided above. I also understand that it is my responsibility to notify Stamated LLC dba Accurate Diagnostics of any change in this information.
This authorization is only effective for the visit date ("Date") listed on this form. I must submit a new authorization at each visit to Stamated LLC dba Accurate Diagnostics if I wish to have future laboratory results sent to me by e-mail.
I understand that Stamated LLC dba Accurate Diagnostics has no control over who may have access to the e-mail address I have listed to receive my lab results.
Electronic Signature Agreement: You acknowledge that you have read the terms above and by checking the "I agree" box below, you are accepting this as your consent to have the requested test administered. *