Consent and Disclaimer

At the time you order a test, you will be asked to sign the following Consent and Disclaimer.

I have requested the specific laboratory test(s) listed above.

Laboratory results from Cinch® are for informational purposes only and are not a substitute for medical advice, diagnosis or treatment.

I am aware that I should consult a physician/healthcare provider before I stop, start or change any treatment plan, including the use of medication.

I am responsible for consulting a physician/healthcare provider.

Neither Cinch®, nor its employees, will interpret the results for me.

I understand that results within the reference (normal) range do not ensure health.

I understand that results that fall outside the reference range may not indicate disease.

I understand that lab tests are not a substitute for a full medical evaluation.

I understand that reactive (positive) results to Hepatitis A, Hepatitis B or GC/Chlamydia must be reported to my local County Health Department according to specific regulations.

I will not hold Cinch®, its Officers, Directors and employees, its affiliates, program sponsors and agents, including the owners/operators of this facility, or its parent companies, their Officers, Directors and employees liable for any outcomes which may result from my participation in this testing option.

If I have requested that my results be mailed to me, I retain all responsibility should someone else at that address access these results. I have also provided a phone number at which I can be reached in the event that critical values are reported.

I understand that I am expected to pay Cinch® in full at the time of service and that no other billing will occur. If I am eligible to receive Medicare benefits, I am aware that Medicare does not cover this service and I am fully responsible for payment at this time.

I understand that a copy of the Summary Notice of Privacy Practices and the entire Notice of Privacy Practices is available should I request it.

If the results show I have HIV, I acknowledge that I will pursue contact with a healthcare provider, public health clinic or AIDS information organization for further information on additional testing or treatment options. I acknowledge that I have had the opportunity to review information with the following details about HIV testing:

  • HIV is the virus that causes AIDS and can be transmitted through unprotected sex (vaginal, anal, or oral sex) with someone who has HIV; contact with blood as in sharing needles (piercing, tattooing, drug equipment including needles), by HIV-infected pregnant women to their infants during pregnancy or delivery, or while breast feeding.
  • There are treatments for HIV/AIDS that can help an individual stay healthy.
  • Individuals with HIV/AIDS can adopt safe practices to protect uninfected and infected people in their lives from becoming infected or being infected themselves with different strains of HIV.
  • Testing is voluntary and can be done anonymously at a public testing center.
  • The law protects the confidentiality of HIV test results and other related information.
  • The law prohibits discrimination based on an individual’s HIV status and services are available to help with such consequences.
  • The law allows an individual’s informed consent for HIV related testing to be valid for such testing until such consent is revoked by the subject of the HIV test or expires by its terms.