Antigua and Barbuda
Bolivia, Plurinational State of
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Cocos (Keeling) Islands
Congo, the Democratic Republic of the
Falkland Islands (Malvinas)
French Southern Territories
Heard Island and McDonald Islands
Holy See (Vatican City State)
Iran, Islamic Republic of
Isle of Man
Korea, Democratic People's Republic of
Korea, Republic of
Lao People's Democratic Republic
Macedonia, the Former Yugoslav Republic of
Micronesia, Federated States of
Moldova, Republic of
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Sint Maarten (Dutch part)
South Georgia and the South Sandwich Islands
Svalbard and Jan Mayen
Syrian Arab Republic
Tanzania, United Republic of
Trinidad and Tobago
Turks and Caicos Islands
United Arab Emirates
United States Minor Outlying Islands
Venezuela, Bolivarian Republic of
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Client Consent Form
Each client is required to read, acknowledge, and agree to the terms in this Consent Form before his/her 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 agreeing to the conditions in this form, the client authorizes Nutrigenomix to:
Analyze his/her DNA for specific nutrition and physical activity‐related genetic markers. Store his/her anonymized DNA sample in a safe and secure location, so that as the science develops he/she will have the option of having additional tests. You may request to have your sample destroyed by emailing [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?
There are no known risks associated with Nutrigenomix testing. 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. 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.
Note: Nutrigenomix does not test for genetic predisposition to certain disease. The test only includes genes related to nutrition and physical activity. Nevertheless, if an individual has a Nutrigenomix test, he/she is 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 not intended to treat, prevent, mitigate, or cure disease. Nutrigenomix does not provide medical advice, diagnosis or treatment. The test looks at 70 genes that have been shown to modify response to dietary intake and/or to impact nutrition and physical activity recommendations. The development of chronic diseases can be influenced by many factors, including genetics, diet and lifestyle. Following the recommendations provided does not guarantee absence of disease. The test results are based upon probabilities, and may not provide a 100% definitive conclusion to either elevated or typical risk.
How will the information be protected?
All personal health information, including Nutrigenomix test results, is protected by the healthcare professional 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.
All sales are final. All Nutrigenomix tests and services are non-refundable.
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.