• STEP 2 - Practitioner Enrollment Form

    Thank you for your interest in enrolling in our Research Program. Please complete the form below and upon approval, you will receive an email with next steps.

  • SECTION 1 — Practitioner Identity

  • Format: (000) 000-0000.
  • State(s) of License
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  • PLEASE GO TO PAGE 2 TO COMPLETE -- CLICK "NEXT" TO COMPLETE YOUR REGISTRATION

  • Understanding and Agreement in Research

    You are enrolling as a Practitioner into a Research Program utilizing a Research Use Only (RUO) spike protein test.
    • SECTION 1 - Research Use & Legal Acknowledgment 

    • Research Use Only (RUO) Acknowledgment

      This laboratory assay is offered for Research Use Only (RUO). It has not been cleared or approved by the United States Food and Drug Administration (FDA) for diagnostic or clinical use. Results are provided for research and informational purposes within a practitioner-directed framework.

    • Non-Diagnostic Use Statement

      I understand that results generated through this program are not intended to diagnose, treat, cure, mitigate, heal, or prevent any disease and should not be used as the sole basis for medical decision-making.

    • Practitioner Responsibility

      I acknowledge that I am solely responsible for interpretation of results, communication with my patient/participant, and any clinical decisions made within my professional scope of practice. Javelin Sciences does not practice medicine and does not provide treatment recommendations.

    • Marketing & Representation Restriction

      I agree that I will not market, advertise, or represent this assay as diagnostic, FDA-cleared, or clinically validated for disease detection. I will accurately describe the assay as Research Use Only.

    • De-Identified Data Use Authorization

      I understand that de-identified data derived from testing may be used by Javelin Sciences for research, quality improvement, validation studies, and program development purposes.

    • SECTION 2 — Program Attestation

    • I attest I am a licensed healthcare professional acting within scope.

    • I understand this testing program is Research Use Only (RUO) and not diagnostic.

    • I understand results are not intended to diagnose, treat, cure, mitigate, heal, or prevent.

    • I agree results will be interpreted within a practitioner-patient relationship.

    • I agree not to market this test as diagnostic.

    • SECTION 3 — Results & Responsibility

    • I acknowledge results will be delivered only to me.

    • I am responsible for communicating results to participant.

    • I agree to maintain HIPAA compliance within my practice.

    • SECTION 4 — Consent Versioning (Legal Control) 
    • Effective Date*
       - -
      2 digit month, 2 digit day, 4 digit year
    •  

    • Submission of this form does not guarantee program approval. Javelin Sciences reserves the right to approve or deny practitioner enrollment at its discretion.

    • Today's Date*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Would you like to be added to our Directory for individual Participants to select and work with you?
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