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Informed Consent

Informed Consent for Home Collected RT-PCR and Serology Tests

This is a consent form for the following information associate with products and related services purchased through checkmesafe.com (the "Website"), which is operated by Apostle, Inc. and its respective officers, directors, employees, representatives, and agents ("ApostleDx").

1. Authorization for use and disclosure of personal health information.

1.1. I voluntarily consent and authorize ApostleDx for the use and disclosure of my personal health information, including the information I provide through the Website and communication with customer support, medical information, and test results (“Personal Health Information”) to receive products, services, and test results.

1.2. I consent my required Personal Health Information to be disclosed to the California Department of Public Health (CDPH) by California Code of Regulations: Title 17, Division 1, Chapter 4, Subchapter 1, Article 1.

1.3. I voluntarily consent and authorize ApostleDx to use my Personal Health Information to conduct scientific research for the purposes of better understanding and consecutive better controlling of sexual transmitted diseases (STDs). I acknowledge and understand that the sexual transmitted infection (STI) test results will be de-identified in the scientific research.

1.4. I voluntarily consent and authorize ApostleDx to release my required Personal Health Information to my insurance company if the testing is billed through my insurance.

2. Authorization and consent for RT-PCR and/or serology testing of home collection specimen submitted.

2.1. I voluntarily consent and authorize ApostleDx to conduct home collection kit provision, specimen receiving, testing, and analysis for the purposes of RT-PCR or/and Serology tests for STI. I acknowledge and understand that my RT-PCR or/and Serology tests will require the collection of an appropriate and adequate amount of sample through recommended collection procedures.

2.2. I understand that ApostleDx is not acting as my medical provider, and that this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree to seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.

2.3. I understand that, as with any medical test, there is the potential for a false positive or false negative test result. I understand that there are risks and benefits associated with undergoing RT-PCR or/and Serology tests for STIs.

2.4. I understand that, after testing, ApostleDx will not return the remaining sample to individuals or physicians. Samples will be retained in the laboratory in accordance with the laboratory’s specimen retention policy.

3. Consent for service/product restrictions and patient identification.

3.1. I understand that I must be 18 years old or above to order and receive the products and services on the Website.

3.2. I understand that I must be resident out of Alaska (AK), Hawaii (HI), and Arizona (AZ) state to order and receive the products and services on the Website.

3.3. I agree to provide my real identity information through patient registration, in accordance with the specimen provider and information on the label of specimen, and to take full responsibility for any discrepancies.

4. Consent for service terms and timeline. I understand and voluntarily accept the service terms on the Website, and that timelines described in the service descriptions are strictly estimates only that cannot be guaranteed. Actual timeline may vary significantly due to volume and technical reasons.

Release to the fullest extent permitted by law. I hereby release, discharge, and hold harmless to Apostle, Inc., including, without limitation, any of its respective officers, directors, employees, representatives, and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my STI test or the disclosure of my Personnel Health Information.

I, the undersigned, have read, understand, and agreed to the statements contained within this form. I have been informed about the purpose of the STI tests, procedures to be performed, potential risks and benefits, and associated costs. I have been provided an opportunity to ask questions before proceeding with STI test(s) and understand that if I do not wish to continue with the collection, testing, or analysis of the test(s), I may decline to receive continued services. I have read the contents of this form in its entirety and voluntarily consent to undergo testing for STI(s).

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