Client Consent Form
Each client is required to read, acknowledge, and agree to the terms in this Consent Form to provide their Informed Consent before their sample can be processed. This ensures each client knows what to expect, understands the process, is aware of the benefits, limitations and potential risks, and understands fully the service being provided before agreeing to proceed. By providing "Informed Consent" the client confirms that they are at least 18 years of age or is the parent/guardian providing consent on behalf of a minor, and is able to comprehend what they are consenting to, and that they are providing this consent freely, voluntarily and without duress. By agreeing to the conditions in this form, the client authorizes Nutrigenomix to:
- Analyze their DNA for specific nutrition and physical activity-related genetic markers and/or markers which influence individual variation in drug response.
- Store their anonymized DNA sample in a safe and secure location, so that as the science develops, they will have the option of having additional tests. A client may request to have their sample destroyed by emailing [email protected] [email protected].
What are the benefits?
Following the nutrition and physical activity recommendations based on the results of the genetic test has been shown to reduce the risk of chronic disease and promote optimal health and performance. Research also shows that individuals who receive DNA‐based dietary advice find the information more motivating to adopt healthier eating habits, and make more changes to their diet compared to when they are given general population‐based dietary advice.
What are the risks?
Some individuals may worry that their genetic information could be used to discriminate against them in their job or for health insurance coverage. In the United States, the Genetic Information Non‐discrimination Act (GINA) was signed into law in May of 2008 and offers federal protection against such discrimination. The federal Health Insurance Portability and Accountability Act (HIPAA) of 1996 prohibits employers and health insurers from excluding individuals from group coverage due to genetic predisposition to certain diseases. Neither HIPAA nor GINA prohibits life insurance policies from using this information. Most states in the US have additional and varied legislation intended to safeguard genetic information. In Canada, the Genetic Non‐Discrimination Act (GNA), formally known as Bill S‐201, was passed into law on May 4, 2017. GNA protects individuals from insurance companies and employers from using, requesting or requiring genetic test results. Under GNA, employers cannot use a person's genetic test results to make decisions about hiring, firing, job assignments, or promotions. Under GNA, the Canadian Human Rights Act bans discrimination based on genetic characteristics. GNA does not prohibit insurers from using information about an individual's current symptoms and diagnoses, even if the condition has a genetic basis. Family medical history is not protected by GNA. If an individual has a Nutrigenomix test, they are required to answer ‘yes' on any legal forms or questionnaires that ask whether they have had a genetic test.
What are the limitations?
Nutrigenomix testing is provided strictly for general informational and educational purposes only and is not intended to be used as medical advice or to diagnose, treat, prevent, mitigate, or cure any medical condition or disease. Nutrigenomix does not provide medical advice, diagnosis or treatment. Nothing in the Nutrigenomix reports constitutes medical advice, diagnosis, treatment recommendations, dietary prescriptions or a professional opinion of any kind. The Nutrigenomix reports are not a substitute for the independent clinical judgment, expertise and training of a qualified healthcare professional with knowledge of your circumstances, medical history, allergies, contraindications, concurrent medications or treatments, and overall health status. To the fullest extent permitted by applicable law, Nutrigenomix expressly disclaims all representations and warranties, including any implied warranties of merchantability, fitness for a particular purpose, accuracy, completeness or reliability. Factors such as age, diet, ethnicity, family health history, and/or personal health, not related to genetics can also impact the likelihood of developing certain conditions or exhibiting certain drug reactions. The test looks at genes that have been shown to modify response to dietary intake and/or to impact nutrition and physical activity recommendations. Following the recommendations provided does not guarantee absence of disease. Based on testing results, patients should not make changes to their medications or medical care including, but not limited to, starting or stopping medications, changes in dosage or frequency of medication without the advice of and consultation with a qualified healthcare professional. The test results are based upon probabilities, and may not provide a 100% definitive conclusion to either elevated or typical risk. The information in the Nutrigenomix reports is not intended for children or for women who are pregnant or nursing.
How will the information be protected?
All personal health information, including Nutrigenomix test results, is protected by the healthcare professional or clinic providing the test. Each sample is anonymized using a barcode and this is entered into a password protected online system. Nutrigenomix uses a Secure Socket Layer (SSL) protocol to encrypt information that is transmitted over the Internet. This technology uses 256‐bit encryption, which ensures that confidential information and transactions cannot be viewed, intercepted or altered. Nutrigenomix will never reveal client information or genetic data to a third party except as required to provide the services requested, or as required by law.
What will happen to the DNA sample once the client has received the results?
After testing is completed, Nutrigenomix will store the anonymized sample under secure conditions to enable future testing as new markers are discovered. Nutrigenomix will never share your data with any third party and will never conduct research using your DNA without your permission.
Refund Policy
All sales are final. All Nutrigenomix tests and services are non-refundable.
Other Charges
There may be a charge for rerouting or resending the package if the address is not entered correctly on the order form. There may be a charge for the sample recollection if the sample is collected improperly.
Client Consent
I have read, or have had read to me, all of the above statements and understand the information regarding Nutrigenomix testing. I have had the opportunity to ask any questions I have about the testing, procedure or risks prior to providing my consent. By providing my saliva or buccal swab sample I am consenting to Nutrigenomix testing and storage of my sample for future testing. By clicking the box below, I consent to:
- Having my Nutrigenomix report sent to me via email by my healthcare practitioner, which I understand is not a secure form of communication. I understand that only my first name is indicated in the report and no other identifying information is included.
- Subscribing to the Nutrigenomix Newsletter list for matters related to order fulfillment as well as receiving educational, marketing or promotional material from time to time. I understand that I can unsubscribe from the email list at any time by following the unsubscribe link or by emailing [email protected].
