Apex Clinical Laboratories, LLC

(331) 318-8600


Bolingbrook, IL

In consideration of receiving over-the-counter COVID-19 tests provided by Apex Clinical Laboratories (“the Company”), I hereby release, waive, discharge, covenant not to sue, and to hold harmless for any all purposes Company and its employees, members, shareholders, officers, servants, agents, or staff (herein referred to as “indemnitees”) from any and all liabilities, claims demands, injuries (including death), or damages, including court costs and attorney fees and expenses, that may be sustained by me while using any products received from the Company.

I am fully aware that the over-the-counter tests provided by Company may involve products that have not gone through a full FDA approval process and instead obtained emergency use authorization (EUA) or registered and are pending such processing and that the results could produce false positives or false negatives or be administered in a way that otherwise produces inaccurate results, or they are laboratory-developed and shown similar performance to EUA authorized reagents. These tests have been validated in accordance with the FDA guidance document (policy for diagnostics testing in laboratories certified to perform high complexity testing under CLIA prior to emergency use authorization for coronavirus disease-2019 during the public health emergency) issued on February 29, 2020. I am also fully aware that the Company is not providing medical care or giving a medical diagnosis via such tests and that I should consult my physician as to the results of any tests.

I hereby waive my rights regarding protected health information under HIPAA to the extent necessary to allow Company to fulfill any orders I submit. Protected health information will not be reused or disclosed by Company to any person or entity other than the above, except as required by law.

I authorize the Company or its agents to bill my insurance provider or insurance program for such tests, which will be provided to me at no cost. If I have requested monthly shipments of over-the-counter tests, I authorize the Company or its agents to periodically bill my insurance provider or insurance program for such tests until I request shipments of tests to no longer be sent to me.

By signing below, I agree that am voluntarily submitting an order for over-the-counter COVID-19 tests and that I acknowledge and represent that I have read, understood, and signed this agreement voluntarily.