AUTHORIZATION OF DATA PROCESSING AND INFORMED CONSENT FOR THE
DNA FITNESS AND/OR NUTRITION TEST
Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:
Me, hereby grant permission for
,with legal age, identified with CC / CE
No, (hereinafter the client) with the signing of this "Authorization Data Processing and Informed Consent" I
agree that I have read, know and understand the paid service and I have taken the decision , conscious,
express, informed and spontaneous I authorize ECOSUSTENTABLES SAS, a company identified with Nit
900998707-6, as responsible to give processing of my personal data in accordance with Policies Treatments
Personal data established by ECOSUSTENTABLES SAS and to preserve the information for an indefinite
period. As far as I understand this document ensures that I know and understand the DNA sample analysis
process, I am aware of its benefits, limitations, potential risks and fully understand the diagnosis that will
be known and delivered exclusively to the following email.
By signing this document, the CLIENT likewise authorizes ECOSUSTENTABLES SAS, to:
Send your DNA sample to clinical laboratories for analysis and obtain the specific genetic markers related
to nutrition and/or exercise.
Prior authorization keeps your sample anonymously for a maximum period of 6 months in a safe place,
facilitating the performance of new genetic tests without requiring an additional sample. In any case, the
realization of new genetic tests will have a cost defined by ECOSUSTENTABLES S.A.S.
Save all information that is delivered by me in the execution of the contracted service such as my name,
identification number, age, address of residence, email address and any other necessary information in
order to obtain the service by part By ECOSUSTENTABLES SAS.
SPECIAL AUTHORIZATION SENSITIVE PERSONAL DATA. I have been sufficiently informed that the
information resulting from the analysis of the genetic markers is sensitive information and that I authorize
the treatment thereof to ECOSUSTENTABLES S.A.S., in case the information should be known by the latter.
In accordance with Article 6 of Decree 1377 of 2013 I am aware that I am under no obligation to authorize
the processing of my sensitive data and that it is optional to answer any questions that may be asked about
my sensitive data. I also authorize ECOSUSTENTABLES S.A.S., to transmit or transfer my sensitive data to
the clinical laboratories that are required in order to obtain the results object of the service I contract.
PURPOSE: ECOSUSTENTABLES SAS will use the information you provide for: 1. Perform the necessary steps
for the development of the contractual and post contractual step towards respect of any underlying
contractual relationship you have with her or third parties related to ECOSUSTENTABLES SAS and comply
To Colombian or foreign law and the orders of judicial or administrative authorities. 2. For internal and /
or commercial administrative purposes such as
statistical analysis, sending of commercial advertising or marketing information, market research, billing
data, and offering and / or recognition of legal and / or contractual benefits.
Your rights as owner PERSONAL INFORMATION: You will have the right knowledge, access, modify,
update, withdrawal of approval and deletion of personal data that will be treated and any other right
according with Article 8 Of Law 1581 of 2012. Those who can exercised in the face of the Responsible of
the treatment through the following channels of communication:
Address:
Phone:
Email:
What is the DNA Fitness and Nutrition Test?
The test consists in a safe and non-invasive oral cell collection kit to provide genetic and reliable
information that will allow you to generate a personalized fitness and nutrition report.
With the collection of buccal cells, specific genetic markers related to fitness and nutrition will be
detected, and a personalized fitness and nutrition report can be generated in case the CLIENT has
previously requested it. Genetic markers are obtained through a unique algorithm that calculates the
relationship between several DNA markers for a given trait, it is determined to what extent this trait is
predominant in an individual.
Benefits
By following dietary recommendations based on genetic results, in some cases, better results have been
detected than those obtained without following the genetic results. Research has also found that people
who receive nutritional advice based on their DNA, find many more motivating tips to adopt healthy eating
habits.
Risks:
There are no risks associated with sampling for genetic tests
Limitations:
The results of these tests are only informative and should not be used for health decision making or
treatment without first consulting a physician. Always consult your physician first.
Test Results are based on probabilities and can’t provide a 100% definitive conclusion to the risk, whether
high, low or typical.
Certain conditions and/or diseases are multifactorial and should not be directly attributed to a genetic
cause. Factors such as environmental and lifestyle are very important variants when determining the risk
of suffering from a multifactorial disease or condition.
These tests only detect the polymorphisms reported in the reports. Therefore, the results of these tests
may not detect any known genetic variant associated with the disease or condition studied under this
analysis.
ECOSUSTENTABLES, nor the suppliers of this or clinics of recommended laboratories guarantee the
obtaining of any type of result expected by THE CLIENT.
How is the information provided protected?
All personal information of the clients, including the results of the test are protected by the laboratory that
provides our service. ECOSUSTENTABLES SAS, will never disclose our customers' information to a third
party, except that it is required to deliver the requested services, or that is required by law.
What will happen to the sample once you have received the results?
Once the test has been completed, ECOSUSTENTABLES S.A.S., with the prior authorization of THE CLIENT
will anonymously store the sample under safe conditions to allow future analyzes in the event that other
new markers are discovered. The sample can be stored a maximum of 6 months at the request of the
client. If the customer doesn’t give authorization samples will be destroyed as soon as the analysis is
finished.
I declare that I have read and understood the authorization of the treatment of my data, as well as the
information related to the test of fitness and nutrition and I accept in their entirety the same with the
signing of this document.
Customer’s general information
Age
Gender
Weight (lbs)
Height (inches)
Date of birth (d/m/y)
Panel
Email Address for Reporting of Results:
I understand and agree that I am financially responsible for the payment I made for
that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the
date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months
period. I agree that my payment made is non-refundable or non-transferable post this period.
I declare that I have read and fully understood all points in this consent and that all of my questions were
answered to my satisfaction and I take the full responsibility of my decision in this consent.
Patient Name & Signature :
Doctor/Therapist Name & Signature :
Witness Name & Signature :
Parent or Gaurdian Name (if patient is minor) :
Date :
Consent to be photographed and published
I, , consent to be photographed and published on Social
media, by while before and after the procedure. I further authorize that the
photographs may be published for any purpose and in any form.