I voluntarily consent and authorize Rythm Health Inc, and Celly Health, Inc. to review the collection, testing, and analysis for the purposes of a diagnostic screening test. I understand that there are risks and benefits associated with undergoing a diagnostic screening testing and there may be a potential for false positive or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have questions or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider. I further acknowledge:
I am the individual who will provide the sample for the Test(s) that I am requesting.
I am at least eighteen (18) years of age.
I have read and understand the information provided about the Test(s) that I have been provided on the website where I requested the Test.
The information I have provided in connection with my request to Rythm Health Inc, and Celly Health, Inc. is correct to the best of my knowledge. I will not hold Rythm Health Inc, or Celly Health, Inc. or their employees or agents responsible for any errors or omissions that I may have made in providing such information.
My health information and results may be shared with Rythm Health Inc, and Celly Health, Inc. employees and agents for the purpose of ordering, processing, and reporting my results.
Medical Services provided by Rythm Health Inc, and Celly Health, Inc. are purely for diagnostic assistance purposes and do not create a physician-patient relationship, and do not constitute medical care or diagnosis or treatment of any condition, disease, or illness.
I authorize Rythm Health Inc, and Celly Health, Inc. to contact me via text message to communicate with me regarding my test.
Patient Rights and Privacy Practices
Notice of Privacy Practices and Patient Rights: Rythm Health Inc, and
Celly Health, Inc. Notice of Privacy Practices describes how it may use and disclose your protected health information for other purposes that are permitted or required by law. To review a copy of notice of Privacy Practices, go to www.rythmhealth.com/privacy.Disclosure to Government Authorities: I acknowledge and agree that my test results and associated information may be disclosed to appropriate county, state, or other governmental and regulatory entities as may be permitted by law.
Release
To the fullest extent permitted by law, I hereby release, discharge and hold harmless, Rythm Health Inc, and Celly Health, Inc. including, without limitation, any its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my diagnostic test or the disclosure of my test results.
I acknowledge and agree that I understand, and agree to the statements contained within this form. I voluntarily consent to proceed with these procedures.