CONSENT FOR GENETIC TESTING
I consent to the collection of my specimens for the purpose of Newtopia GeneticsTM testing. I understand that Newtopia Genetics testing is for educational and informational use only, that it is not designed to diagnose disease or medical conditions, and is not intended to provide medical advice. If I have concerns or questions about what I learn through my Newtopia Genetics test, I will discuss them with my Newtopia Coach, my physician, or both.
Newtopia will use my genetics information, gathered and analyzed by a certified independent laboratory (“Lab”), to provide a simulated guide of the Newtopia program that may include recommendations about nutrition, exercise and behavior management (“Newtopia Programs”).
I understand that a positive (abnormal) test result may provide insight into what may be influencing my overall health and wellbeing and may affect nutrient distribution, activity intensity, and lifestyle modification. 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 are not intended to be used as the sole means for clinical diagnosis or patient care decisions, and that 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 shall be done.
I may request disposal of my sample up to 60 days after the completion of my test by contacting the Lab or Newtopia (New York State residents: sample shall be destroyed within 60 days of collection). I agree to relinquish the Lab, Newtopia and its representatives and affiliates 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 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. 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.
AUTHORIZATION TO USE AND DISCLOSE GENETIC INFORMATION
- The laboratory working with Newtopia and any other laboratories performing my genetic tests to disclose the results of my genetic markers and characteristics relevant to my participation in the Newtopia Programs, along with my demographic information, including my name, date of birth, and contact information (collectively, “Genetic Information”) to Newtopia, Inc., 116 West 23rd Street, Suite 19, New York, NY, 10011, for use in connection with the Newtopia Programs and for Newtopia to provide me with the results of my genetic tests.
- I authorize Newtopia and its affiliates to disclose my Genetic Information to my Newtopia coach.
I understand that once my Genetic Information has been disclosed, federal privacy laws may no longer protect my Genetic Information. I understand that this Authorization is voluntary and that my treatment, payment for treatment, enrollment or eligibility will not be conditioned on whether I refuse to sign this Authorization.
I understand that I may revoke this Authorization at any time and for any reason by writing to Newtopia at email@example.com. I understand that my revocation will not be effective for information already used and disclosed in reliance on my Authorization. By signing this Authorization, I authorize Newtopia to retain my Genetic Information for one year from date signed or until I revoke this Authorization or request that my Genetic Information be destroyed, at which time this Authorization will expire (unless an earlier expiration date is required by applicable law).
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