The following eligibility questions are going to help us understand more about you and your medical history. Please read each statement or question carefully and select any that apply. Contact Gene Matrix if you need assistance. Thank you!

Patient acknowledges receiving information about the medical treatment/procedure to be performed by Meta Gene (Gene Matrix LLC) hereunder and has fully discussed and understands the nature and scope of such treatment/procedure and the potential risks of such treatment/procedure.

Patient has been informed that:

1. All medical procedures/treatments carry some risks and complications may occur.
2. Additional procedures or emergency treatments may be needed in the event of complications.
3. The procedure/treatment may not give the expected result even though the procedure is carried out with professional care.

Patient acknowledges and agrees as follows:

1. I am at least 18 years of age.

2. I understand the nature of the procedure/treatment and that undergoing the procedure/treatment carries risks.

3. I have had the opportunity to ask questions and I am satisfied with the explanation and the answers to my questions.

4. I understand that I may withdraw my consent at any time prior to receiving any treatment/procedure.

5. I consent to the anesthetic, medicines, or other treatments, including any emergency procedures which could be related to this procedure/treatment.

6. I understand that Gene Matrix will seek reimbursement opportunities from my health insurance company even if I do not provide my insurance information using a system called Discovery.

7. I assume complete and take full responsibility to take appropriate action regarding my test results. I agree that I will seek medical advice, care, and treatment from my medical provider if I have questions or concerns, or if my condition worsens.

8. I consent to the use of my Protected Health Information (“PHI”) by Gene Matrix, for the purpose of submitting claims to my health insurance provider and such other purposes that are permitted under the Federal Health Insurance Portability and Accountability Act (HIPAA) for reimbursement of genetic tests ordered in person, on the phone or through the Gene Matrix website.

9. I consent to Gene Matrix. submitting claims to my health insurance provider, and I assign my right to receive any health insurance or other benefits in connection with the genetic tests ordered to Gene Matrix. to permit Gene Matrix. to submit such claims. I authorize payment directly to Gene Matrix. for such claims.

10. I consent to Gene Matrix. and any reference Labs and/or my health insurance provider contacting me in connection with the genetic tests ordered, including via email, phone, or text message. I consent to Gene Matrix. sharing my PHI to any reference labs that are contracted to run the test. Reference labs in our laboratory network at times help Gene Matrix. to run tests.

11. I agree that, by ordering the Genetic test or taking such tests, I am not entering into a doctor-patient relationship with Gene Matrix., or any entity or person affiliated with Gene Matrix., and that any questions I may have concerning such tests, including but not limited to the results of such tests and any treatment, follow up, or other issues relating to such tests, are solely my responsibility.

12. I hereby wave my rights regarding protected health information under HIPAA, to the extent necessary to complete any testing and to allow Gene Matrix. to provide the results (whether positive or negative) of testing to (1) the organization which has arranged for the testing, (2) local and state public health authorities (which may result in further direct communication from those entities to me for further follow-up and contact tracing). Protected health information will not be reused or disclosed by Gene Matrix. to any person or entity other than the above, except as required by law.

In signing this Informed Consent to Medical Treatment, I acknowledge and represent that I have read it, I understand it, and sign it voluntarily.