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This Informed consent gives BodyK permission to conduct the BodyKnows Biomarker Assessment or/and the BodyK Fit Screening. Please read this Consent carefully.

I understand that:

• I am entitled to receive a copy of this Informed Consent, my screening results, and any other protected health information that is collected by BodyK in connection with my preventive screenings.
• A diagnosis can only be made by a qualified physician or licensed healthcare professional.
• The results collected here by BodyK will be held securely and confidentially by BodyK
• The screening results will not be used by BodyK for purposes of individual health information or to make a diagnosis of any disease or illness.
• BodyK is a preventive health screening and education company that provides information and supports its community wellness initiative. BodyK does not practice medicine and is not a substitute for my doctor’s care.
• I am responsible for contacting my primary care doctor for questions about any specific medical needs that may be indicated by these biometric screenings. I will not hold BodyK responsible for providing information, diagnosis or treatment as a substitute for the care I receive from my physician or other qualified healthcare provider.
• If I have a concern about my screening result, I am responsible for following up with my primary care physician.
• I recognize that if I do not sign this Informed Consent, BodyK cannot proceed with the preventive screening. I have had full opportunity to read and consider the contents of this form.

I hereby grant BodyK permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of BodyK and will not be returned.

I hereby irrevocably authorize BodyK to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

I hereby hold harmless, release, and forever discharge BodyK from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

By signing this I am acknowledging that I have read and understand BodyK’s Notice of Privacy Practices. I have had full opportunity to read and consider the contents of Privacy Practices. I understand that, by signing this acknowledgement and consent form, I am giving my consent for this office’s use and disclosure of my protected health information to carry out treatment, payment activities and health care options.

A copy of our Notice of Privacy Practices is available online on our website. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices which will contain the changes. These changes may apply to any of your protected health information that we maintain. You may obtain another copy of our Notice of Privacy Practices, including revisions, at any time by contacting our Privacy Officer at Luciana.Leo@bodyk.net. This consent does not expire after one year.