I agree to abide by Rockdoc Consulting Inc’s (“Rockdoc”) cancellation and rescheduling policy respecting appointments.
Specifically, if I cancel or reschedule with more than SEVENTY-TWO (72) HOURS’ notice, I agree to pay an administrative fee to Rockdoc of TWENTY-FIVE CANADIAN DOLLARS ($25 CAD).
If I cancel or reschedule with less than SEVENTY-TWO (72) HOURS’ notice, I agree to pay an administrative fee to Rockdoc of SIXTY CANADIAN DOLLARS ($60 CAD).
If I cancel with less than TWENTY-FOUR (24) HOURS’ notice, or If I am later than FIFTEEN (15) MINUTES for my appointment,
I acknowledge that I will be deemed to have missed my appointment entirely and I will have forfeited my entire appointment fee.
I confirm that I am undergoing this private Covid-19 test (the “Test”) Rockdoc on an entirely voluntary basis and I confirm that I do not have any symptoms of COVID-19 AND (i) I am fully vaccinated and have not tested positive for COVID-19 in the last 5 days OR (ii) I am not fully vaccinated, and have not come into unmasked contact with a known positive COVID-19 case for more than 10 minutes or tested positive for COVID-19 in the last 10 days.
I understand that by submitting to the Test, I will be releasing certain private information about myself (including the information in this form and any other medical information I disclose to Rockdoc and its staff during the Test), and that the results of the Test (the “Results”) are also considered part of my private information (altogether the “Private Information”). The Private Information may be transmitted via electronic means, including but not limited to email, texting, or via certain mobile applications.
I hereby authorize the release of my Private Information (a) to me to my email address or by text message to my phone number, both set out above; and (b) to those entities managing approved mobile applications and related software for the handling and dissemination of the Private Information through electronic means, as noted above; and (c) to relevant public health authorities on a “need-to-know” basis, having regard to the infectious nature of Covid-19 as a serious communicable disease and the current pandemic situation in and throughout Canada and the world. I also acknowledge that the Results may also be anonymously pooled with the results of other persons in order to determine community prevalence or other statistics related to COVID-19, and these results may be reported or published.
I authorize Rockdoc, its staff and laboratory partners to conduct and coordinate specimen collection, swab storage, transportation, testing, and reporting for COVID-19 via a bilateral anterior nasal or other alternative swab (altogether the “Services”). As with any biological test, I understand that there is the potential for false positive or false negative results. I hereby recognize that Rockdoc is relying on third party efforts, data and laboratories and agree to hold Rockdoc harmless and clear of any liability if Test results are not accurate. In particular, I hereby release and hold Rockdoc harmless from all liabilities in the event that the Test yield results that do not meet the entry requirements of any country or if Test results are not accepted by departing or arrival airports or authorities for any reason.
I understand that Test turnaround times will be met on a best-efforts basis, but that no specific time frame has been guaranteed.
If my Test is reported as positive for COVID-19, I may be contacted directly by Rockdoc and by the appropriate public health authority and may be asked to attend a public health or other location for additional testing. I also acknowledge that a positive Test result means that I must self-isolate and comply with all directives provided by relevant public health
I understand that neither Rockdoc nor its laboratory partners are acting as my medical service provider or medical practitioner, this testing does not replace treatment by my medical service provider or medical practitioner, and I assume complete and full responsibility to take appropriate action with regards to the Test I agree I will seek medical advice, care and treatment from my medical provider and local health authority if I have questions or concerns.
I hereby consent for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily agree to this Test and waive any and all rights, claims, or causes of action of any kind whatsoever arising out of my participation in this Test, and do hereby release and forever discharge Rockdoc, its laboratory partners, and their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury or loss, including but not limited to cancellation or interruption of my planned travel, illness, paralysis, death, economical or emotional loss, that I may suffer as a direct result of my participation in this activity, including traveling to and from any location related to this activity.
Should I require medical care or treatment or if I am denied entry to any destination, I agree to be financially responsible for any costs incurred for such treatment. I agree to indemnify and hold harmless Rockdoc and their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns against any and all claims, suits, or actions of any kind whatsoever for any fees, costs, liability, damages, compensation, or otherwise brought by me or anyone on my behalf, including legal fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf.
I, the undersigned, hereby confirm I am at least of the age of majority in the jurisdiction that I am principally resident in (or alternatively, I am the parent / legal guardian of the person submitting to the Test) and have been informed about the Test purpose, procedures, possible benefits and risks, and the collection and disclosure of my Private Information associated therewith. I have been given the opportunity to ask questions before I sign, and I understand that I can ask additional questions at any time.