PWN Informed Consent

Last updated on July 30, 2019

BY CLICKING “I ACCEPT,” I ACKNOWLEDGE THAT I HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS INFORMED CONSENT. IF I DO NOT CLICK “I ACCEPT”, I WILL NOT BE ABLE TO USE OR RECEIVE THE SERVICES.


General Informed Consent

I agree to receive the services provided by PWN Remote Care Services (with its affiliates, affiliated professional corporations and its administrative services provider, PWNHealth, LLC, collectively, “PWN” “PWNHealth”, “we” or “us”) relating to ordering the CBC (includes Differential and Platelets) laboratory tests (“Tests”), including, without limitation, physician oversight, ordering of laboratory Tests, customer support or counseling and any other related services provided by PWN or its service providers and partners (the “PWN Services”).

  1. I have read and understood the information provided about the Test that I are have requested - Test Information.
  2. I am the individual who will provide the sample for the Test that I am requesting.
  3. I am at least eighteen (18) years of age.
  4. I certify that when I receive PWN Services, I will be physically present in the state of which I have notified PWN.
  5. I agree that the information I submit in connection with the PWN Services is truthful and accurate. I will not hold PWN or its healthcare providers responsible for any errors or omissions that I may have made in providing such information.
  6. I agree that the PWN Services are provided solely for informational purposes, and do not constitute treatment or diagnosis of any condition, disease or illness.
  7. While the applicable laboratory conducting the Test implements safeguards to avoid errors, as with all laboratory tests, there is a chance of false positive or false negative.
  8. I agree to contact the PWNHealth Care Coordination Team if I do not receive results within ten (10) days after I provided a sample to the laboratory’s patient service center.
  9. I am responsible for checking my email and logging on to my account to view my results, when available.
  10. I agree that the PWN Services do not replace the existing primary care or other relationship with my physician and are not being used as a substitute for the care, medical advice or treatment provided by my primary care or other personal physician.
  11. I agree that the PWN Services are for my personal use.
  12. PWN Services will be provided using electronic communications, information technology, or other means between me and a health care provider who are not in the same physical location. Such services may include the electronic transmission of medical records, photo images, personal health information, or other data between I and a health care provider. There are potential risks associated with the use of technology, including disruptions, loss of data and technical difficulties. I understand and acknowledge that all remote health providers will determine whether or not the service provided is appropriate for such methods. I understand that I may withdraw my consent to such services at any time by contacting PWN at the contact number or email below. Further, I agree that I understand that I may have to travel to see a health provider in-person for certain care, diagnosis and treatment matters.
  13. I agree that I are solely responsible for forwarding the test results to my primary care or other personal physician and for initiating follow up with my primary care or other personal physician for care, diagnosis, medical treatment or to obtain an interpretation of the laboratory test results.
  14. I agree that I will not make medical decisions without consulting a healthcare provider or disregard medical advice from my healthcare provider or delay seeking such advice based on information as a result of the use of the PWN Services.
  15. PWN does not and will not prescribe or order any drugs or medication.
  16. I understand that if I am eligible, AstraZeneca will pay for the PWN Services and laboratory test.

I authorize PWN to use the email address and phone number I provided in connection with my registration at the time I requested the Test to contact me in connection with the PWN Services. I am responsible for contacting PWN's Care Coordination Team at the contact information above to notify them of any changes to my mailing address, email address, phone number or other information that I provided in connection with the PWN Services.

I understand that testing is voluntary and that I may withdraw my consent to testing at any time prior to the completion of the Test or to PWN Services by contacting PWN's Care Coordination Team at 888-362-4321 or emailing patientservices@pwnhealth.com.

I have read this Informed Consent carefully, and all my questions were answered to my satisfaction. I hereby consent to participate in the PWN Services pursuant to the terms, conditions, standards, and requirements set forth herein, in the PWN Terms of Use, PWN Privacy Policy and PWN Notice of Privacy Practices or as otherwise provided to me.