Orient Pharmaceuticals & Biologicals

NAME OF PHYSICIAN*:

CLINIC/HOSPITAL*:

DIAGNOSTIC TEST*:

I HAVE BEEN INFORMED BY MY PHYSICIAN ABOUT THE PURPOSE OF THE TEST AND ITS LIMITATIONS.
I UNDERSTAND THAT THE RESULTS OF THE TEST WILL BE SENT OR MADE AVAILABLE TO MY PHYSICIAN AND WHEN THE RESULTS ARE READY, I WILL COLLECT THE INFORMATION FROM MY PHYSICIAN.
I HAVE BEEN INFORMED WHO MAY HAVE ACCESS TO MY SAMPLE (“SAMPLE”) AND TEST RESULTS WHICH FORM PART OF MY CONFIDENTIAL MEDICAL RECORDS. I ALSO UNDERSTAND THAT PERSONAL INFORMATION RELATING TO ME, INCLUDING MY NAME, DATE OF BIRTH, CONTACT DETAILS, SAMPLE DETAILS AND TEST RESULTS WILL BE PROCESSED AND STORED BY THIRD PARTIES NECESSARILY INVOLVED IN THE PROCESS OF ORDERING, TAKING, COLLECTING, DELIVERING AND TESTING MY SAMPLE AND I HEREBY GIVE MY CONSENT TO SUCH PROCESSING AND STORAGE.
AFTER THE TEST HAS BEEN COMPLETED, I UNDERSTAND THAT MY SAMPLE MAYBE DISPOSED OF UNLESS ADVISED OTHERWISE.
I AUTHORIZE ORIENT PHARMACEUTICALS FZ LLC OR THEIR DESIGNEE TO COORDINATE THE PICK-UP, COURIERING AND DELIVERY OF MY SAMPLE THROUGH THE COURIER COMPANY SELECTED BY OXFORD PHARMACEUTICALS OR ITS NOMINEE AT ANY GIVEN TIME. I AGREE TO THE COURIER’S TERMS AND CONDITIONS AND AUTHORIZE THE COLLECTION OF MY SAMPLE FROM THE LABORATORY, CLINIC OR HOSPITAL WHERE MY SAMPLE IS TAKEN AND TO ARRANGE FOR IT TO BE CLEARED THROUGH THE REQUIRED AUTHORITIES AND DELIVERED TO THE RELEVANT TEST CENTRE OUTSIDE MY COUNTRY OF RESIDENCE.
I AUTHORIZE THE TEST CENTRE TO PERFORM THE TEST ON MY SAMPLE AND TO SEND THE RESULTS TO MY PHYSICIAN NAMED ABOVE.

I AGREE THAT THE TEST ORDER FORM SIGNED BY MY PHYSICIAN WILL BE SENT TO THE RELEVANT TEST SERVICES PROVIDER. I ALSO UNDERSTAND THAT I MAY BE CONTACTED DIRECTLY BY OXFORD PHARMACEUTICALS CUSTOMER SERVICES BY PHONE, EMAIL OR OTHER MEANS IN RELATION TO THE PAYMENT FOR, PICK-UP, COURIERING AND OR DELIVERY OF THE SAMPLE.

I UNDERSTAND THAT I AM RESPONSIBLE FOR ENSURING THAT ALL CHARGES RELATING TO THE PERFORMANCE OF THE TEST ON MY SAMPLE ARE PAID BY ME OR ON MY BEHALF.

I HAVE READ AND RECEIVED AN ELECTRONIC COPY OF THIS PATIENT CONSENT FORM AND I AGREE TO UNDERGO THE ABOVE INDICATED TEST. I UNDERSTAND THE INFORMATION SET OUT ABOVE AND I HAD THE OPPORTUNITY TO ASK ANY QUESTIONS THAT I MIGHT HAVE HAD REGARDING THE TEST AND THE PROCESS RELATED TO THE TEST AND RECEIVED SATISFACTORY ANSWERS FROM MY PHYSICIAN.

PATIENT NAME*

TODAY’S DATE*

PATIENT COUNTRY*

Patient Consent Form