RapidTestMe LLC assures you that should your Protected Health Information (PHI) be made available to us, we will protect it and will not disclose it except in the circumstances required by law. We will comply with the rules and regulations concerning the privacy and security of PHI under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Also at the request and direction of the customer and if feasible, RapidTestMe LLC will make available PHI in accordance within the requirement of HIPAA.

I understand that the possible risks and side effects of blood work which include but are not limited to:
- Discomfort, bruising or pain at the injection site
- Inflammation of the vein used for injection
- Lightheadedness
- Rash or skin irritation
- Fainting or low blood pressure

I understand the information provided on this form. I have received all of the information and explanation I desire concerning the procedure(s) and consent to the performance of those procedure(s).

I release of RapidTestMe LLC and all the staff from all liabilities for any complications or damages associated with drawing my blood.

My signature below confirms that:
a. I understand the information provided on this form and agree to the foregoing.
b. The procedures set forth above have been adequately explained to me by my physician.
c. I have received all the information and explanation I desire concerning the procedures.
d. I authorize and consent to the performance of the procedure(s).