Consent for Services
This consent form (“Consent”) reviews the benefits, risks and limitations of you, as the person who has created a user account (referred to as “you” or “your”), utilizing the Services provided by DM6 Health. (referred to as “DM6”, “we”, “us” or “our”). It also explains how your information and sample(s) will be used after performance of the Services.
By clicking on the box or sending in your sample, you indicate that this Consent is a binding agreement and that you have read and understood the following terms. Capitalized terms used but not defined in this Consent have the meaning given to them in our other policies.
By clicking on the box or sending in your sample, you have chosen to use our Services and have given your informed consent to have your biological sample(s) tested for biomarkers and to have information related to your use of the Platform and Services shared to your insurance company. This information includes but is not limited to: test results, your contact information, your preferred clinical provider. Biological samples shall consist solely of human fluids and/or tissue samples, depending on the test purchased, that are intended to be analyzed for the individual’s sole use, and not for any other purpose, including but not limited to research, publications, commercial uses, or any other purpose other than to inform the purchaser’s health and/or wellness. For the purpose of clarity, this limitation applies only to individual use and does not apply to DM6. DM6 may use de-identified test results for statistical research studies and publications.
Our Services are offered and available to users who are 18 years of age or older and are residents of Canada and United States. Your use of DM6’s Services is voluntary. It is your choice whether to utilize our Services or not. Prior to signing this Consent, you may wish to speak with your insurance company or your healthcare provider for further guidance about our Services.
PROCEDURES AND PROTOCOL FOR DM6 TESTS
WHEN YOUR ACCOUNT IS CREATED, WE USE SOME OF THE INFORMATION PROVIDED BY YOU OR ON YOUR BEHALF. WE CANNOT PERFORM THE SERVICES WITHOUT COLLECTING THIS INFORMATION, BUT WE WILL ONLY COLLECT INFORMATION THAT WILL ASSIST US IN PROVIDING THE SERVICES THAT YOU HAVE REQUESTED. IN ORDER FOR THE SERVICES TO BE PROVIDED AS INTENDED, YOU OR THE PARTY ACTING ON YOUR BEHALF MUST PROVIDE ACCURATE AND CORRECT INFORMATION. FAILURE TO PROVIDE REQUIRED INFORMATION OR TO EXECUTE REQUIRED DOCUMENTS MAY RESULT IN YOUR SAMPLE(S) NOT BEING TESTED.
ALL REQUESTS FOR TESTS WILL BE REVIEWED BY A LICENSED DOCTOR (“HEALTH CONSULTANT”) AFFILIATED WITH A COMPANY THAT WE HAVE PARTNERED WITH TO PROVIDE REVIEW AND AUTHORIZATION OF TESTING, REVIEW OF LAB RESULTS, AND COUNSELING WHERE APPLICABLE. SERVICES WILL NOT BE PROVIDED TO YOU IF A HEALTH CONSULTANT DOES NOT AUTHORIZE YOUR REQUEST AND ORDER THE APPLICABLE TEST(S). WE WILL REFUND YOUR INSURANCE COMPANY THE APPLICABLE FEES FOR SUCH CANCELED TESTS.
YOU WILL COLLECT THE BIOLOGICAL SAMPLE(S) (I.E., BLOOD, STOOL, SALIVA AND URINE) THAT WILL BE PROVIDED TO AND TESTED BY ONE OF OUR DESIGNATED TESTING LABORATORY PARTNERS (“LAB”). YOU WILL SEND THE SAMPLE(S) DIRECTLY TO THE LAB WHERE YOUR SAMPLE(S) WILL BE TESTED FOR A NUMBER OF BIOMARKERS.
THE RESULTS OF YOUR TEST(S) WILL BE MADE AVAILABLE TO YOU THROUGH OUR SITE AND WILL ALSO BE MAILED TO YOU AND YOUR HEALTHCARE PROVIDER, IF APPLICABLE. IN THE EVENT WE DETERMINE THAT A BIOLOGICAL SAMPLE IS NOT SUITABLE FOR TESTING DUE TO THE CONTENT OF THE SAMPLE OR BECAUSE WE BELIEVE THE SAMPLE TO HAVE BEEN SUBMITTED IN VIOLATION OF THIS CONSENT OR THE USER AGREEMENT, WE RESERVE THE RIGHT TO WITHHOLD THE RESULTS AND TO NOT PROVIDE A REFUND TO YOUR INSURANCE COMPANY. WE WILL DETERMINE AND ESTABLISH NORMAL RANGES FOR ALL TESTS IN CONJUNCTION WITH OUR LABORATORY PARTNERS BASED ON THEIR VALIDATION AND PROFICIENCY TESTING PROCEDURES. IF YOUR RESULTS ARE CLINICALLY SIGNIFICANT OR HAVE A CRITICAL VALUE THAT FALLS OUTSIDE OF OUR ESTABLISHED NORMAL RANGES BY AT LEAST A CERTAIN AMOUNT, A HEALTH CONSULTANT WILL MAKE REASONABLE EFFORTS TO CONTACT YOU BY TELEPHONE.
Utilizing our Services to discover what your biomarkers say about you can help you gain a better perspective on your health and how your body functions. You may use this information to make more informed health care decisions and choices. A summary of the potential benefits of our tests is included below.
Potential Benefits Include Learning More Information About:
Your body’s ability to control glucose levels.
Colorectal Cancer Screening Test (FIT)
Screening for blood in stool which may indicate a risk for colon cancer.
Screening test for anyone who may be at risk for kidney disease or dysfunction
More information about the specific benefits of our tests and Services are available on our Site.
In order to utilize our Services, you must collect the appropriate biological sample(s) for the test(s). Some of our tests require a stool sample; there are no risks associated with collecting stool samples using the containers provided in our test kit(s). Some of our tests require the collection of a blood sample. Although the risks and discomforts associated with a blood draw are very low, you might be at risk for excessive bleeding, fainting, feeling light-headed, bruising, hematoma (blood accumulating under the skin), or infection (a slight risk any time the skin is broken). If you have a history of excessive bleeding or fainting while having blood work done, we advise avoiding our tests that require self blood collection.
Disclosing certain information may make you uncomfortable. The results of the tests provided by these Services will be shared with your insurance company, which is covering the cost of the Services. The results of the tests provided by these Services will also be shared with the clinical provider that you designate, if any, during registration. Our Services include biomarker tests that may reveal sensitive information about your health. DM6, or the Health Consultant who reviews your results, may advise you to have a follow-up visit with your doctor after reviewing the results of your test. As a result, you may learn about health conditions and problems or potential health risks that you were not aware of before you utilized our Services. You may experience stress, anxiety, or emotional or doctor discomfort when you learn about health problems or potential health problems. The tests may also identify a health risk for a condition that you do not ultimately get diagnosed with, which can lead to stress, anxiety, or emotional or physical discomfort. There may also be additional risks of utilizing our Services that are currently unforeseeable.
OUR SERVICES DO NOT PROVIDE MEDICAL ADVICE. The information and content provided, including but not limited to text, graphics, images, videos, and other material contained in the Services, are for informational purposes only and are not intended as a substitute for professional medical advice, help, diagnosis or treatment. Always seek the advice of your doctor or other qualified health care provider with any questions you have regarding your medical care, and never disregard professional medical advice or delay seeking it because of something you have read on or via our Site. Nothing contained in the Services is intended to constitute a medical diagnosis or treatment. Reliance on any information appearing in the Services, including but not limited to information provided by DM6 or by other users of the Services, is solely at your own risk. By clicking your acceptance, you understand and agree that your results are not intended to be used for any diagnostic purposes and are not a substitute for professional medical advice. You understand that our Services are for information and educational use only; DM6 does not provide medical services, diagnosis, treatment, or advice.
DM6 does not warrant the accuracy, completeness, timeliness or usefulness of the opinions, content, services or other information provided through the Services or on the Internet generally. DM6 and its affiliates, licensors, and suppliers have no control over and accept no responsibility for your compliance with the laws applicable to your state of residence.
DM6 implements several safeguards to avoid technical errors, but as with all medical tests, there is a chance of a false positive or a false negative result. A false positive result means a biomarker was detected, which is not in fact present. A false negative result means the test failed to identify a biomarker that is in fact present. Other sources of error include sample mix-up, poor sample quality or contamination, and technical errors in the laboratory. Some biological factors, such as a history of bone marrow transplants or recent blood transfusions may limit the accuracy of the results or prevent the Services from being completed.
Science and our knowledge of biomarkers’ meanings are constantly changing. New information may replace or add to the information that we used to interpret your results. We are not obligated to notify you if there is a new understanding of biomarkers that might result in a change to the interpretation of your results. We reserve the right to contact you, at our option, in the future.
RETENTION AND USE OF YOUR INFORMATION
We are subject to multiple laws on the retention of data. Accordingly, we retain any information collected about you for as long as we are required to maintain it for regulatory and compliance purposes or for a legal or business necessity.
You will send your biological sample(s) directly to the Lab that will conduct the test. DM6 has no obligations or liability regarding the retention of your sample(s). You understand that by providing any sample, having your sample processed, accessing your results, or providing information to us, you acquire no rights in any research or commercial products that may be developed by DM6 or its collaborating partners. You specifically understand that you will not receive compensation for any research or commercial products that include or result from your sample or information.
Your information and test results may be stored in a repository and used for validation, educational, and/or research purposes.
WITHDRAWAL OF CONSENT
Your use of DM6’s Services is voluntary. You may choose to withdraw your Consent or to stop using DM6’s Services at any time. Such requests should be sent to us by email at email@example.com or in writing to DM6 Health, 5000 Dufferin Street, Unit E2, North York, Ontario, M3H 5T5, Canada.
Please note that while any changes you make will be reflected in our databases within a reasonable period of time, we may retain your information in the ordinary course of business, for the satisfaction of our legal obligations, or where we otherwise reasonably believe that we have a legitimate reason to do so.
If you have questions or comments about our Services or this Consent, please contact us by email at firstname.lastname@example.org or by phone at +1 416 477 4602, or in writing to DM6 Health, 5000 Dufferin Street, Unit E2, North York, Ontario, M3H 5T5, Canada.
FOR & WHERE COVID-19 TESTING IS A SERVICE:
DM6 provides COVID-19 testing for screening purposes. Convenient testing with rapid results, means efficient identification and isolation of disease, and, ultimately, reduced community spread. This means that our members and their families can return to work or school and travel as quickly as possible.
DM6 uses PCR testing which is approved by Health Canada and can reliably detect the presence of the COVID-19 virus in a person’s body. Our secure [digital system/online portal/secure website] allows users to book their test and receive their results confidentially.
Specimen collection is conducted by a healthcare professional with oversight by a licensed medical professional.
DM6 provides two types of testing:
- Antigen Tests; and
- RT-PCR Tests.
Consent to Treatment
You have engaged DM6 to provide Covid-19 testing and to obtain rapid results of the testing either in a DM6 testing centre, your home or office or at a mobile location. You have engaged DM6 to provide Covid-19 testing solely for the purposes of a third-party (e.g. school, employer, travel related).
DM6 does not provide Covid-19 testing to individuals who are eligible for Covid-19 testing in accordance with the Ontario Ministry of Health’s provincial Covid-19 testing guidelines. DM6 does not provide Covid-19 testing to any individuals who are symptomatic, who have been exposed to a confirmed case of Covid-19 confirmed by local public health or the COVID Alert App, or who live or work in a setting that has a Covid-19 outbreak as identified by a local public health unit. Individuals who require tests for the above purposes should follow the guidance of their health care provider and/or Ontario public health officials and follow Ontario public health guidance and/or visit an Ontario Covid-10 Assessment Centre as applicable and necessary.
By signing this form, you confirm that you do not have any Covid-19 related symptoms including:
Migraines and Headaches
By signing this form, you confirm that you have not been in contact with or exposed to someone with Covid-19 or someone with a confirmed Covid-19 case.
By signing this form, you consent to the following:
- I confirm I have requested Covid-19 Testing from DM6.
- I attest and confirm that I have read the above provided to me and the provincial Covid-19 testing guidelines.
- I confirm that I do not meet the eligibility criteria for COVID-19 testing (e.g. am symptomatic or have been exposed to a confirmed case of the virus as notified by local public health or the COVID Alert app, or live or work in a setting that has a COVID-19 outbreak as identified by a local public health unit).
- I am requesting COVID-19 testing solely for the purpose of a third party (e.g. work, school, airline, border guidelines, etc).
By attending for Covid-19 testing and signing this form, you confirm the following:
- I understand that COVID-19 Screening Testing will be performed by DM6. The test will be requisitioned by a DM6 Health physician and the specimen will be collected by a healthcare professional who collect a sample using a deep nasal swab.
- On the day of your appointment, the DM6 representative will do a symptom check, will ask you some questions and perform a bilateral anterior nasal swab in the shallow nasal cavity. This test is not intrusive and is completed in 30 seconds. Your specimen will be sent to an accredited laboratory for processing. The results will be communicated to you by email.
- I agree that should my test indicate a positive result for COVID-19 I will consult with public health and/or my own primary care physician or healthcare provider for specific advice that takes into account my medical history and personal health.
- I have been advised of the nature of the COVID-19 screening testing including the expected benefits, risks, side effects, alternative courses of action. I have had the opportunity to ask questions about the COVID-19 screening testing to my satisfaction and have had my questions answered.
Consent to Collection, Use and Disclosure of Personal Health Information
- In providing its services (Covid-19 testing), it is necessary for DM6 and its staff to collect, use, retain, and disclose my personal health information (PHI) in certain and limited circumstances and specifically to share my PHI with an external laboratory, as necessary.
- In addition to the collection, use and disclosure of PHI for the purposes of providing COVID-19 testing services and results, I agree that my PHI may be used for the following purposes:
- ensuring the effective operation of DM6’s testing program;
- providing results to the DM6 physician who will report, as required by law, any positive COVID-19 test results to public health.
- I understand that COVID-19 testing results will be communicated to me via the email address that I have provided. I understand that the use of technology may increase the risk of my PHI being unintentionally disclosed or intercepted by third parties and that technical failures and technological issues may result in a loss of PHI and/or delay or interruption. DM6 and its staff do not assume responsibility or liability for any technical failures or technological issues associated with delivering results by way of email. I agree and understand and have been advised that email communication is an unsafe way to communicate PHI but have agreed to proceed in this way. I will notify DM6 if I do not consent to receiving electronic communications so that alternate arrangements can be put in place for me to receive information from DM6, including my Covid-19 test results.
- I understand that if my test indicates that I am positive for COVID-19, I will be contacted by email, unless I advise DM6 of alternate ways to communicate positive results with me.
- I understand that if my test indicates I am positive for COVID-19, DM6 is required by law to report this to public health. Public Health will be provided with my name, address and phone number to enable contact tracing and the provision of COVID-19 support as needed.
- I may withdraw my consent for the collection, use and disclosure of PHI by refusing to participate in future COVID-19 screening testing and/or providing written notice to DM6’s Privacy Officer at email@example.com. I understand that any withdrawal of consent is not retroactive.
By selecting the “I ACCEPT” button, you are signing this Consent Form electronically.
You are consenting to COVID-19 screening testing and for the collection, use and disclose of my PHI as described in this form.
You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.
Last Modified: November 9, 2022