Consent And Release For Screening (Page 3 of 3) in pdf

CONSENT AND RELEASE FOR SCREENING

This form

must be completed

before your screening

Page 3/3

First Name:

Surname:

D.O.B:

M / F

Location:

(Date of Birth)

(Gender)

Your Consent

Please read through and agree the following statements:

CONSENT AND RELEASE FOR SCREENING

I have correctly answered the above questions to the best of my knowledge. I understand that failure to do so may

adversely affect the screening process and Screenetics cannot be held liable for results following the supply of

misinformation by me.

I hereby consent to the drawing of a blood sample and agree to provide a urine sample (if requested) for the purpose of

the health check to obtain medical data (as stated in the test package), the results of which shall be provided to me

during my consultation. I hereby consent to a DEXA x-ray being conducted on my foot for the purpose of measuring my

bone density (applicable screening only).

In consideration of the above procedures and measurements, I hereby release Screenetics UK Ltd and any other

organisation(s) associated with this screening, their affiliates, directors, officers, employees, successors, and assigns

from any and all liability arising from or in any way connected with these procedures the associated measurements or

from data derived there from.

I understand that:

The responsibility for initiating a follow up examination to confirm the results of this screening and obtain professional

medical assistance is mine alone, and not that of any organisation(s) associated with this screening.

If any of the results suggest that I may be at an increased risk according to the guidelines I agree it is my

responsibility to inform my doctor of this.

The data derived from this test is to be considered preliminary only and does not constitute a diagnosis of any

condition, but I understand that I should obtain further professional medical assistance.

Client medical data remains fully confidential between Screenetics and the client. Clients consent to the

anonymous use of their medical data for statistical purposes by Screenetics. All client data is protected under the Data

Protection Act 1998 and as such will be securely stored and destroyed in accordance with the law.

Your contact details are safe with us! We will never pass them on to third parties, or share your details without your

prior express consent.

Screenetics may from time to time utilise non-medical client data to keep you informed on our latest offers and

□

information. If you do not wish to receive such information, please indicate by ticking here.

Screenetics is a trading style of Screenetics UK Limited.

Date:

Signed: …………………………………………….

Office Use Only

Reference:

Screening Type:

Extra Tests:

Fasting:

Conducted by:

Stats:

Age:

Height:

Weight:

| keeping you on your perch!

Screenetics UK Limited, Registered in England No. 06151366.

Consent And Release For Screening Page 3

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