Fill and Sign the Consent Release Form

Blood Test Consent and Release Form I hereby consent to the drawing of a blood sample for the purpose of measuring my blood cholesterol (TC, HDL, LDL, TC/HDL Ratio), triglycerides and/or glucose level(s). I have had the opportunity to read and consider the __________________________ (Name of Program; e.g., Total Wellness) (TW) Privacy Practices Notice to my satisfaction prior to consent. I accept that services, including counseling/explaining of results, might be rendered in a non-private setting. Furthermore, I hereby release and forever discharge for myself, my heirs, executors, administrators and assignees, TW and their employees, owners and representatives, as well as the company sponsoring this event and their agents, representatives, employees, successors, assignees, governing bodies, and advisory committees from any and all claims, demands, actions and causes of action, which may result from participation in this program. I understand and accept that: 1. Data derived from this test is to be considered preliminary only and does not constitute any kind of diagnosis. 2. The responsibility for initiating a follow-up examination to confirm results and obtain professional advice and medical treatment is mine and not that of TW or any other organization associated with this screening. 3. TW will keep my results strictly confidential and may release only aggregate data to my employer or other organizations. 4. If my company has ordered follow up counseling related to certain screenings and I meet the requirements for this service, I will be contacted for a counseling session to go over my results. 5. TW will keep my results strictly confidential and may release my data to a 3rd party vendor, which will anonymize it before sending it to my employer for the purposes of wellness program development. Signature: ___________________________ Today's Date: _________________________