Breath sample collection and service provision consent form
This consent form is phrased in male tense for convenience's sake only, but everything contained in it is designated for both women and men
Prognose Bakeman-Dogman Company (hereinafter: "the company") offers its customer service aimed at assisting in early detection of different types of cancerous cells based on odor, using dogs trained to respond to particular odors, as described below herein (hereinafter: "service").
The service includes (a) arrival of a company authorized representative to the address provided by the customer to deliver the sample kit that includes: sterile mask packed in a bag with a barcode used to identify the customer, another bag to store the mask after the sample is provided, a sheet with instructions on providing the sample (hereinafter: "sample kit"); (b) Collection of the sample kit in coordination with the customer after taking the sample at the address provided by the customer; and (C) Analysis of the sample by the company and sending the sample analysis results.
The customer takes the sample on his own, according to company instructions provided on the company website at the following address: firstname.lastname@example.org.
72 hours after the sample is collected, the company will send the customer a report with results of the sample analysis on a form sent to the e-mail address provided by the customer to the company when registering for the service.
Service is stipulated as follows: (a) The customer provided the company with the details necessary to contact him and verify his identity while registering for the service; (b) Payment for service provision; (C) Filling out the questionnaire on this address; and (d) Customer's full consent to the terms of service specified herein without any reservation by signing the consent form herein at the bottom of the document.
One may register for the service again by ordering a new sample kit after at least ninety (90) days have elapsed from the date on which results of the previous sample were delivered.
The signatory below, whose details are specified below herein ("customer") hereby confirms, consents and declares the following by putting his signature:
1. The customer is an adult legally able to read, comprehend and sign this consent form, constituting the terms of service.
2. The customer hereby confirms he has operated, prior to sending the sample, according to company instructions that appear on the company website [email@example.com], including refraining from eating and drinking for 30 minutes prior to collection of the sample.
3. The customer is aware that the service is not medical, does not constitute "medical advice" or replace such advice, general or individual, considering the special data and needs of each customer, and does not constitute "medical diagnosis". The customer comprehends the results of the sample analysis in any case do not attest to a particular medical condition or the customer's health and the service does not constitute an alternative to medical tests. Additionally, the customer understands the service is not designed for self-diagnosis purposes, prevention or treatment of diseases or health diagnosis lacking medical or other clinical data.
4. The customer is aware that in no case may results of the sample analysis comprise a medical or other instruction or recommendation. The customer comprehends the service is designed to provide the customer with general indication only.
5. The customer hereby consents and agrees results of the sample analysis or any other information provided by the company do not constitute an alternative for professional opinion provided by a certified party who will examine all the customer's relevant personal details. In any case of medical problem or suspicion of a problem, the customer bears exclusive responsibility to consult a certified party as soon as possible.
6. The customer comprehends the general information he receives does not serve in any way as a replacement for receiving advice from a medical or another therapeutical party. Additionally, the customer understands the sample results do not replace medical tests that may only be carried out by a certified party. The customer is responsible for using discretion according to the circumstances and consult a physician or another treating party in case of need, and not rely on the sample results only.
7. The customer understands the company cannot provide any warranty regarding the results, their precision or correctness and the customer hereby agrees the company will not be liable in any way for results, use he makes of the results or relying on them. For this matter, it must be noted receiving results of the sample analysis does not attest to the fact that no further action is needed, or additional tests, intended to prevent morbidity or improve the customer's health.
8. The customer hereby agrees the sample kit is designed for the personal use of the person that signed this consent form only.
9. In some cases, the company may not be able to process the customer's sample, e.g., if the provided sample lacks sufficient quality or quantity, or the sample was contaminated due to incorrect storage of the sample mask. Furthermore, the customer is aware that there may be errors in the sample analysis process. Therefore, the customer is aware that there may be mistakes, defects or imprecisions in the information that may be collected from the sample or in the way it was delivered to the customer, and the customer hereby declares he is aware of the above and hereby exempts the company or anyone acting on its behalf from any responsibility or liability relating to an error, defect or imprecision of the type described above.
10. The customer is aware and agrees that should the original sample mask be damaged for any reason in a manner that requires collecting another sample, the customer will cooperate with the company to schedule a date for delivery of a new sample, without further expense to the customer. It should be noted that in no case will repeated or second tests be made on a single sample mask after results are submitted. An intact sample mask will be tested by the company only once.
11. The customer declares he received all information he requires from the company in order to make a decision whether he is interested or not in said service and properly comprehends the significance of said service.
12. The customer confirms his consent to the terms of service was provided of his own free will and without any coercion.
14. The company will not be responsible or liable towards the customer or any third party for damage of any type, direct or indirect, that was caused or may be caused to the customer or any third party due to provision of the service or use made by the customer of the sample analysis results. Should a final verdict determine the company is liable towards the customer or any third party in any way, the customer hereby agrees the company's liability towards him will be limited to the sum the customer actually remitted to the company in return for provision of said service