This consent form relates to health services provided by Safe Return Solutions (referred to in this form as “SRS”) that is described below (services provided are referred to in this form as “Health Services”).
This consent form is to be signed by either:
(a) the person who wishes to take part in the Screening; or
(b) if the person who is to take part in the Screening is under the age of 16 years, their parent or guardian.
Please read this consent form carefully and ensure that any questions that you have about the contents of this consent form and/or the Health Services are answered for you before you agree.
Health Services provided by Safe Return Solutions include, but are not limited to Screening Services, Vaccine Services and Information Seminars. Such services are referred to in this form.
Safe Return Solutions is a trading name for a partnership between Advanced Medical Services and Titan Experience:
- ED Advanced Medical Services Limited, a company incorporated in Ireland under registered number 484181 and having its registered office at Birchgrove House, Ballyorban, Monkstown, Co. Cork
- Titan Experience business details to follow
- The purpose of the Screening is to detect the possibility that the person who takes part in the Screening may have, or is at risk of developing, the condition(s) or disease(s) that the Screening has been developed to detect.
- The Screening is offered by SRS for the purpose of detecting risk or comparison to previous baseline results and not for diagnostic purposes. As with all health screenings, there is a possibility that the Screening may produce a false positive result(meaning that the results indicate that the condition or disease in question is present when in fact it is not present) or a false negative result (meaning that the results indicate that the condition or disease in question is not present when in fact it is present). SRS accepts no responsibility for any false positive results or false negative results that are produced by the Screening.
- If the Screening produces results that SRS considers to be abnormal, SRS may, if SRS considers it appropriate, forward a copy of the results to the medical doctor nominated by you. Alternatively (for example, where the screening involves finger prick cholesterol or glucose checks or vision testing), SRS may verbally inform you of the results of the Screening and recommend to you that you consult with your doctor in relation to the results. Responsibility to follow up on the results with your doctor and to obtain any medical care or to make any lifestyle changes that the results indicate may be needed or which your doctor or other health advisor recommends lies solely with you. SRS accepts no responsibility for any failure by you to follow up with your doctor or to seek or obtain any necessary medical care prescribed or for any dietary and/or lifestyle changes that you are advised should be made not being made.
- If available in relation to the Screening, SRS may be in a position to arrange certain follow-up tests that may have been recommended as a result of your participation in the Screening if you would like us to do so.
- If this is a corporate Screening, you agree that at the time of availing of services related to and including the Screening, you are an active employee or if applicable, a qualified dependent of an active employee.
- You acknowledge that the email you have provided when booking your appointment is the email that you choose to use for accessing your results and agree that if you have chosen to provide the email address of an adult other than yourself such as a spouse, partner, or dependent; this person may also have access to your Personal Data including Screening results.
- If receiving a Vaccine Service, you acknowledge that you have been presented with information regarding the possible side effects of the vaccine. You will be given an opportunity to ask questions about the vaccine and side effects at your appointment before administration of the vaccine.
- The results of the Screening will be held by SRS and will be treated by SRS as strictly confidential and will be disclosed by SRS only to:
(a) the person who has taken part in the Screening (or if the person is aged between 16 years and 18 years, to the person and/or to their parent or guardian where SRS considers that it is in the best interests of the person to do so) or, if that person is under the age of 16 years, to their parent or guardian;
(b) their nominated doctor;
(c) if SRS is able to arrange follow-up tests at your request, the persons involved in arranging and conducting those follow-up tests as necessary; and
(d) if the Screening involves biological sample screening services, the laboratory facility.
(e) as some of the services covered by corporate screenings will be taxable, it is essential that your employer is aware of the taxable claims made in the financial year. This will involve providing the employees name and the total amount of taxable services used by you and your dependents. No details will be provided on the services used, or who used them, only the total cost.
(d) the relevant Government body of the country where you reside at the time of your screening, if this Government has directed that results of screening for infectious diseases must be shared for public health reasons.
- SRS will not disclose the results of the Screening to any other person without your prior written consent. We may, however, from time to time use or disclose the results for statistical purposes in an anonymised or aggregated format only from which the person who has been screened cannot be identified. The data shared with third parties unless explicitly consented by the member will not be stored as identifiable information.
- If necessary to provide Health Services, SRS will collect and hold some or all of the following data in relation to the person taking part in the Health Services:
(c) any additional contact information;
(d) date of birth;
(e) gender and race or ethnicity;
(f) medical history;
(g) general health information;
(h) biological data recorded during screening;
(g) the results of the Screening;
(h) if applicable, the main sport(s) and recreational activities in which the person participates; and
(i) if applicable, the name and contact details of the person’s parent or guardian;
(referred to in this form as the “Personal Data”).
- SRS is committed to complying fully with its obligations under the General Data Protection Regulation (GDPR) in respect of the Personal Data that it holds. By registering your information on the form to avail of screening you hereby consent to the processing of your sensitive personal data in accordance with the General Data Protection Regulation (GDPR). Your personal data will only be used for the above-mentioned purpose and will be kept safe and secure at all times.
- SRS will keep an accurate and up to date record of the Personal Data. SRS will keep the Personal Data securely stored electronically. The person to whom the Personal Data relates (or, if they are under the age of 16 years, their parent or guardian) will have the right to see a copy of any records that we will hold on computer or on paper relating to him or her and to request that we correct any inaccuracies in those records. In the case of a person who is aged between 16 years and 18 years, SRS reserves the right to permit this right of access to be exercised by the person’s parent or guardian only or by the person and their parent or guardian jointly where we consider that it is in the best interests of the person to do so. To obtain a copy of the Personal Data, please visit our website, www.ameds.ie, to obtain the relevant contact details for SRS.
- If you have any questions or concerns regarding the Personal Data that we hold relating to you or the person who has been screened, please contact us using the contact details set out on our website.
- SRS will not pass on the Personal Data that we hold to any third party other than those persons who are referred to in this form without your prior written consent. The data shared with third parties unless explicitly consented by the member will not be stored as identifiable information.
- If SRS is able to arrange follow-up tests, SRS will need to forward the Personal Data, the results of the Screening and, if required, the name of the doctor to whom the results of the follow-up tests are to be sent to the hospital, clinic, consultant or doctor who will arrange and conduct the follow-up tests. Those persons will have obligations under the General Data Protection Regulation (GDPR) in relation to their use and disclosure of the Personal Data.
- SRS abides by HSE recommended retention schedule for medical data including but not limited to the retention of Personal Data for adults age 18 and older for 8 years, and the retention of Personal Data for persons under the age of 18 until such persons reach the age of 25.
- If a person enters their Personal Data for the purpose of the Screening, but cancels before the Screening takes place and as such no medical data is recorded, the person may request that their Personal Data be deleted immediately without applicable retention schedule.
CONSENT & Confirmation
By signing (Ticking the box), I:
- confirm that I have read and understood the Health Service information provided to me by SRS and understand the nature, process and risks associated with the Health Service;
- confirm that I have submitted all information correctly and accurately and that I will inform SRS if such information changes in advance of any appointment;
- consent to take part in the Health Service or to the person under the age of 16 years who is named on the front page of this form taking part in the Health Service (as applicable);
- consent to the results of the Screening being sent by SRS to a doctor or medical specialist for review and interpretation and, if applicable to the Screening, to the medical doctor nominated by me;
- consent to the outcome of my Screening being made known to my school, club or other party with an interest in controlling my permitted activity or otherwise administering any care or requirement arising in relation to the condition or disease the subject matter of the Screening and accepting SRS may not be obliged to notify any third party and that it remains absolutely my own responsibility to ensure that all interested parties are made aware of any condition/disease (suspected or otherwise) and the related steps, actions, activities or restrictions on activities applicable to me;
- consent to the results of my Screening being made known to my place of employment, but only in circumstances where same is required by the Employer to comply with Health & Safety Regulatory requirements or where I am otherwise aware prior to undertaking this Screening that the said results of my screening will be made known to my Employer, however I accept that SRS is not obliged to notify any third party and that it remains absolutely my own responsibility to ensure that all interested parties are made aware of any condition/disease (suspected or otherwise) and the related steps, actions, activities or restrictions on activities applicable to me;
- confirm that I understand that the Screening is carried out for screening purposes only in order to identify possible risks or comparison to earlier baseline results and may not be sufficient for diagnostic purposes and that additional tests may be required in the event that the Screening produces a positive result for abnormality or otherwise depending on the results of the Screening;
- confirm that I understand that, while the Screening is a reliable method of detecting possible abnormalities existing at the time of the Screening, it cannot identify all possible abnormalities and that SRS shall not be responsible for any false positive results or false negative results that may be produced by the Screening;
- confirm that I understand that, irrespective of whether the Screening provides a positive or a negative result for an abnormality or condition (or, in the case of a Concussion Screening Test, where the screening provides a result consistent with my initial baseline test results), I must still fully comply with the course of action prescribed by my treating doctor/GP and that I shall not partake in or return to any activity or sport except as and until cleared to do so by my treating doctor/GP (or other medical doctor/consultant if referred to such medical professional);
- understand and agree that, in the event of a positive result for an abnormality, it is my personal responsibility to arrange follow-up tests and treatment (including medical treatment and dietary and/or lifestyle changes) at my own financial cost (but that SRS may, at my request, be able to arrange follow-up tests) and that such follow-up tests and treatment are not part of SRS’s health screening services and that SRS has no responsibility in connection with the arrangement and the conduct of such follow-up tests and/or treatment and their outcomes or for any such follow-up tests and treatment not being undertaken. This also applies to any organisation that is funding and / or facilitating this service;
- consent to the Personal Data and the results of the Screening being processed and shared by SRS in the manner described in this consent form;
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