CONSENT AND RELEASE
CLIENT CONSENT TO RETENTION, USE, AND DISCLOSURE OF PERSONAL INFORMATION
I, the undersigned, hereby authorize Modify Body, and each of its respective affiliates and subsidiaries (collectively, the “VMediSpa”) and any director, officer, employee, consultant or agent of the Modify Body entities, to possess, retain and disclose my personal information and individually identifying health information described below (collectively, my “Personal Information”), in connection with the delivery by the VMediSpa Entities of certain blood testing services, and other services incidental thereto (collectively, the “VMediSpa Services”):
♦ My full legal name;
♦ My date of birth;
♦ My gender;
♦ My personal healthcare number for laboratory testing;
♦ My email address;
♦ My telephone number;
♦ My home address and postal code;
♦ My attendance at, and the receipt of, Modify Body Services;
♦ The results of blood testing conducted by Modify Body Entities, including any diagnostic, treatment and care information relating thereto; and
In connection with the delivery by Modify Body entities of VMediSpa, I, the undersigned, hereby authorize and permit the Modify Body Parties to use my Personal Information for the following purposes:
♦ To collect, process, store, retrieve and dispose of my Personal Information (including, but not limited to, through cloud based third party storage platforms);
♦ To provide information management or information technology services for other third-party licensed health care practitioners;
♦ To disclose my Personal Information to third-party laboratories, facilities, organizations, service providers, contractors and health care practitioners as required to facilitate the provision of the Modify Body Blood Services;
In addition to the approved and authorized disclosure of my Personal Information in connection with the provision of Modify Body Services contemplated above, I expressly authorize the Modify Body Parties to disclose my Personal Information to the following parties, as required based on the Services performed:
♦ Quest Diagnostic Laboratories
♦ Stage Zero
♦ Life Labs
♦ Any additional 3rd party laboratory that Modify Body may enter into an agreement with in order toprovide the Services as required.
I, the undersigned, hereby acknowledge and understand that the used of my Personal Information and the types of Personal Information that will be held, processed, used and disclosed by the Modify Body Parties may not be exhaustively described in this consent and release (the “Consent and Release”), and I expressly authorize the Modify Body Parties to: (a) collect, use and disclose my Personal Information for purposes that are not described in this Consent and Release; and (b) collect, use and disclose other types of my Personal Information that are not described in this Consent and Release as may be reasonably required by the Modify Body Parties in order to provide me with the Modify Body Services, provided such collection, use and disclose is done in accordance with applicable laws, including, but not limited to, the Personal Information Protection and Electronic Documents Act (Canada), and/or any other equivalent or related provincial or federal privacy, information or health information legislation.
RELEASE – COLLECTION, USE AND STORAGE OF PERSONAL INFORMATION
In consideration of the Modify Body Entities providing the Modify Body Blood Services, and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, to the maximum extent permitted by law, I forever release, remise and discharge the Modify Body Prties and all of their respective predecessors, successors and assigns, including, without limitation, any and all of their respective officers, directors, shareholders, legal advisors, creditors, partners, employees, agents, successors and assigns (collectively, the “Protected Parties”), from any and all actions, causes of action, contracts (whether express or implied), claims and demands for damages, loss or injury, suits, indemnities, expenses, pocket expenses, economic loss, interest, costs and claims of any and every kind and nature whatsoever, at law or in equity (collectively, “Claims”), which against the Protected parties I ever had, now have, or can hereafter have by reason of or arising out of any cause or causes whatsoever existing up to and inclusive of the date of this Consent and Release including, without limiting the generality of the foregoing, anything relating to or arising out of the collection, use and disclosure of my Personal Information as contemplated in this Consent and Release. I waive my right to bring any and all such Claims, including any right to sue the Protected Parties, and I further agree to indemnity and hold harmless the Modify Body Parties from and against any Claims relating to or arising out of the collection, use and disclosure of my Personal Information as contemplated in this Consent and Release.
RELEASE – MODIFY BODY SERVICES AND BLOOD TESTING
In consideration of the Modify Body Entities providing the Modify Body Blood Services, and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, to the maximum extent permitted by law, I forever release, remise and discharge the Protected Parties from any and all actions, causes of action, contracts (whether express or implied), claims and demands for damages, loss or injury, suits, indemnities, expenses, pocket expenses, economic loss, losses incurred from cancellations of any kind of booking, reservation or ticket whatsoever (including, without limitation, flights, buses, trains, vehicles or transports of any kind, accommodations, events or any other bookings, reservations or tickets) interest, costs and claims of any and every kind and nature whatsoever, at law o in equity (collectively, “Blood Services Claims”), which against the Protected Parties I ever had, now have, or can hereafter have by reason of or arising out of any cause or causes whatsoever existing up to and inclusive of the date of this Consent and Release including, without limiting the generality of the foregoing, anything relating to or arising out of any and all delays in the delivery of Modify Body Blood Services (or the related test results) by the Modify Body Parties or by any third-party that the Modify Body Parties work with in connection with the delivery of any Modify Body Services, including, without limitation, any delays in the delivery of results of any blood testing. I waive my right to bring any and all such Blood Services Claims, including any right to sue the Protected Parties, and I further agree to indemnity and hold harmless the Modify Body Parties from and against any Blood Services Claims relating to or arising out of any and all delays in the delivery of Modify Body Services (or the related test results) by the Modify Body Parties or by any third-party that the Modify Body Parties work with in connection with the delivery of any Modify Body Service, including, without limitation, any delays in the delivery of results of any blood testing.
SIGNATURE
I, the undersigned, understand why I have been asked to disclose my Personal Information. I am aware of the risks and/or benefits of consenting, or refusing to consent, to the disclosure of my Personal Information. I understand that I may revoke this consent in writing at any time. I acknowledge that I have been given the opportunity to seek and obtain independent legal advice in connection with signing this Consent and Release.