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cognicheck.com online memory screenings

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INFORMED CONSENT & RELEASE FORM
(Please read and acknowledge)


I hereby release CogniCheck, Inc. and CogniCheck.com, its employees, agents, contractors, and all other organizations and individuals associated with this corporation and/or website from any, and all, liability that may arise or result, either directly or indirectly, from this memory screening and/or any information, data, and/or recommendations that are derived or distributed from this screening. I also understand the following:

 
  1. Although these memory screenings and their results may prove beneficial in identifying memory problems (or within normal limits performances), particularly if all screening instructions, tips, and procedures are strictly followed, they are intended to be utilized only as screening tools and for informational purposes, and they are not designed, or intended, in any way to be conclusive or to provide definitive diagnoses, recommendations, and/or treatments, nor are they designed to be utilized as substitutes for comprehensive examinations/ evaluations, recommendations, and/or treatments by licensed health care professionals. The screening tests and their results are also not designed, nor intended, to be used in any litigation or other legal proceedings. Additionally, no guarantee of benefits has been made to encourage me to undergo a memory screening.

  2. This memory screening is designed to be a one-time assessment and is in no way intended to infer or imply the establishment of any type of ongoing relationship (e.g., doctor/patient) with any health care professional/doctor, organization, and/or individual associated with CogniCheck, Inc. and/or CogniCheck.com.

  3. The results from this screening will remain private and secure consistent with CogniCheck.com's "Privacy" policy. My results, however, with identifying information (e.g., user name) deleted, may be combined with the results of other participants and utilized for scientific research and educational purposes, as well as for other purposes that are deemed appropriate by CogniCheck, Inc. and/or CogniCheck.com. The exception to this privacy is if you indicate (e.g., via e-mail, etc.) that you are planning to harm yourself or someone else. If this occurs, then CogniCheck, Inc. and/or CogniCheck.com will attempt to obtain help for you to prevent such acts.

  4. If any recommendations for future care, including, but not limited to, follow-up examinations and/or treatments, are provided to me, the sole responsibility to follow up with any recommendations lies with me and not with CogniCheck, Inc. and/or CogniCheck.com, its employees, agents, contractors, or any other organizations or individuals associated with the corporation and/or website. CogniCheck, Inc. and CogniCheck.com shall have no liability for claims by, or damages of any kind whatsoever to, a user of this website or any other person for any decision or action taken in reliance on the information contained in, or received via, this website.

  5. I am solely responsible for any future costs that may result in following any and all of the recommendations for future care that may be given to me.

  6. I am ultimately responsible for my own health and well-being and it is my sole responsibility to follow through on any and all potential concerns, difficulties, and/or abnormalities that may be present, or that may arise in the future, by obtaining appropriate health care and/or advice.
Please review the "Privacy" and "Terms and Conditions" statements for additional information regarding your privacy and use of this site.


By clicking below, I acknowledge that I have read, understand, and accept the above statements, as well as the Privacy and Terms and Conditions statements:


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