Consent for Genetics Testing

By signing below, I consent to the collection of specimens from myself (or individual who lacks capacity for consent) for the purpose of Newtopia Genetics DNA testing. I understand that the Newtopia Genetics TM testing is for research and educational use only.  Newtopia Genetics is not a genetic testing lab, a medical genetics company, or a clinical service.  Newtopia Genetics is not designed to diagnose disease or medical conditions, and it is not intended to provide medical advice.  If you have concerns or questions about what you learn through your Newtopia Genetics test, you should discuss them with your Newtopia Coach, your physician, or both.

Newtopia will use the information from a physician prescribed genetic test, gathered and analyzed by a certified independent laboratory, for research study purposes and to guide the customization of personalized lifestyle plans combining nutrition, exercise and behavior management. I understand that my sample will be sent to the Genelex laboratory to identify genetic characteristics that may affect my weight gain and loss as they influence appetite, body fat, and cravings.  These markers are being tested in connection with my participation in the Newtopia Wellness Program and to aid Newtopia in the customization of the Newtopia Wellness Program for me.  The results of these tests may assist Newtopia with making recommendations to me and in the development of an individualized lifestyle plan combining nutrition, exercise, and behavior management.

I understand that a positive (abnormal) test result may provide insight into what may be influencing my weight gain and will allow Newtopia to customize my participation in the Newtopia Wellness Program, including recommendations for nutrient distribution and activity intensity.  I understand that I may wish to consider further independent testing, consult my physician or pursue genetic counseling. The genetic testing being performed is not comprehensive and thus my test results may be negative even if I have a genetic condition because genetic markers that are not being tested or yet discovered are not detected. I understand that genetic test results may be unclear or difficult to interpret due to current understanding of genetic disorders or conditions and/or technical limitations of the test and that the results are not intended to be used as the sole means for clinical diagnosis or patient care decisions. Predicted gene function may change depending upon the emergence of new discoveries, literature, industry standards and guidelines. I may want to have genetic counseling prior to signing this consent. No tests other than those authorized by my doctor shall be done.

I understand that: while DNA testing is highly accurate and widely accepted, as in all testing there is a possibility of delay or error; Genelex may use reference laboratories; Genelex and Newtopia may contact me to obtain additional specimens for testing; and Genelex and Newtopia maintain patient privacy in accordance with HIPAA. I understand that after personal information is removed, my data/specimen may be stored indefinitely by Genelex and/or Newtopia to be used for quality assurance, research studies or medical education. I may request disposal of my sample up to 60 days after the completion of my test by contacting the laboratory (New York State residents: sample shall be destroyed within 60 days of collection). I understand that my results will be shared with my provider who ordered the test. I agree to relinquish Genelex, Newtopia and its representatives from liability for injury that may arise from collecting and testing these specimens and from any effects or actions that the results of these tests may have on me or any other individual. I have been given the opportunity to ask questions regarding purpose, test reliability/ limitations, risks and benefits. I understand that genetic tests may result in my learning information about myself that I do not anticipate and that genetic testing can involve possible medical, psychological or insurance consequences for me. I also understand that sharing my genetic results with others could negatively affect me.  My participation in this genetic testing is completely voluntary and I understand my results will be sent to the ordering physician or facility, and Newtopia in accordance with my Newtopia Authorization to Use and Disclose Genetic Information form.