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Download consent form as a PDF.
General
Informed Consent
Why am I being asked to give consent?
You are being asked to sign this consent form because you would like to order preconception testing through the services provided by Poplin, Inc. (“we” or “us”) and our partners, and we need your permission to facilitate these tests. You understand and agree that ordering these tests is voluntary, and you are under no obligation to do so. Please carefully read this form and speak to a healthcare professional if you have any questions before you sign it. You will be provided with a copy of this form after you sign it.
MINIMUM AGE CONSENT
Only individuals eighteen (18) years of age or older may order a Test Package. Do not complete this form or order a Test Package unless you are eighteen years of age or older. Any Test Package found to have been ordered by an individual under the age of eighteen will not be processed.
What are the tests offered?
For females: Essential, Plus and Premium panels
For males: Essential, Plus and Premium panels
These Test Packages have been designed for pre-pregnancy wellness. It is possible that these Test Packages do not include a test that may be recommended for you based on your personal medical and family history. Before placing an order for your desired Test Package, we recommend that you confer with a healthcare provider. To order the Test Package, you will need to have blood drawn through one of our authorized providers. You may need to sign other forms, provide further information, or review other information when you have your blood drawn.
The Test Package does not constitute medical advice
All material is provided for educational purposes only and is not intended to be a substitute for a consultation with your healthcare provider. The Test Package is not intended to diagnose, treat, or cure disease. You are strongly encouraged to consult and work with an experienced healthcare practitioner. We do not engage in rendering medical advice or services. Individuals with health disorders, medical conditions, or any condition needing medical supervision assume full responsibility for obtaining such professional medical assistance. Consult your physician regarding any symptoms or medical conditions. We specifically disclaim any expressed or implied warranties of merchantability or fitness for any particular usage, application, or purpose. We do not recommend self-diagnosis or self-medication, and no information within this website or presented by us or our associates may be construed or interpreted as recommending self-diagnosis or self-medication.
Where do I go to obtain the blood test and
who will obtain my test results?
You will choose either a qualified Quest Diagnostics Incorporated (“Quest”) Patient Service Center or a mobile phlebotomy service to administer the Test Package you choose. Upon completion of the testing, you will be sent a custom report with your lab results and an explanation of those results though a secure email or via an online patient portal. After obtaining your test results, you may also choose to have an educational call with one of our pre-pregnancy educators to discuss any questions you may have. This call is merely educational and does not constitute medical advice. You should contact your healthcare provider for any medical advice. This service does not replace a preconception visit with a healthcare provider but can be helpful for navigating those conversations.
Your results will be released to or viewed by us, Quest and our selected physician networks. Poplin, Quest, and our physician networks and its healthcare providers will release to each other and share your results and other health or personal information, as needed, for provision of our services and the Test Package. Our physician networks are partners that assist us in the ordering of tests and coordination of results. Positive and/or abnormal results to certain tests in the Test Package may also be released to health officials or others as required under applicable state law.
If a laboratory test result is outside the normal range, you are encouraged to see your healthcare provider. Some tests, to be validated, will need to be repeated at the discretion of a healthcare provider. Laboratory test results may vary depending upon age, sex, time of day blood sample is taken, diet, medications, and the limits of modern technology. A single laboratory test or group of tests cannot guarantee good health. False positive and false negative test results are possible. The results of your Test Package only constitute a partial snapshot of your state of health and do not represent a medical diagnosis or treatment of disease.
It is solely your responsibility to review your results and, if necessary, follow-up with your healthcare provider. All individuals are required to keep up to date contact information on record with Poplin so that we may contact you regarding your results. Failure to review your results and contact a healthcare provider can result in serious health consequences should your test results be positive or abnormal.
Your Consent and Our Limitation of Liability
You are ordering the above Test Package on a voluntary basis and should understand the benefits, risks, and complications associated with these tests. By signing this document, you are acknowledging that you understand the blood tests that you are ordering and your willingness to accept any risks and complications.
You, your successors, heirs, executors, administrators, and assigns, do hereby forever release and discharge Poplin, Inc. and its employees, directors, owners, and representatives from any and all liabilities, claims, demands, actions, damages, and causes of action, which may result from your participation in this program.
By signing this document, you hereby authorize release of your test results and other health or personal information by, to, and between Poplin, Inc., Quest Diagnostics Incorporated and our physician network providers.
Should you order any genetic testing from Poplin, you further authorize release of your test results and other health or personal information by, to, and between Poplin, Inc., Quest Diagnostics Incorporated, Invitae Corporation and our physician network providers.
Please note that tests performed through Invitae are not part of Poplin’s services. All ordering and all results will be processed through Invitae’s website and will be subject to Invitae’s terms and conditions.
POPLIN IS NOT RESPONSIBLE FOR ANY TESTS PERFORMED BY INVITAE AND POPLIN HEREBY EXPRESSLY DISCLAIMS ANY LIABILITY FOR SUCH TESTS.
By signing this document, you hereby represent that you are eighteen years of age or older and that you are a resident of the state you provided to Poplin while ordering your Test Package.
