Consent & Waiver of Liability

The novel coronavirus (“COVID-19”) is a disease that includes several symptoms according to the Centers for Disease Control (“CDC”), such as fever or chills, cough, shortness of breath, nausea, and can lead to death. Currently, no vaccine has been developed for COVID-19. COVID-19 is contagious and means that contact with others, even those who are asymptomatic, or contact with surfaces that have been exposed to the virus, can lead to infection.
I give permission for COVID-19 symptom status, COVID-19 test result status, COVID-19 related risk status, medical history relating to COVID-19, and COVID-19 safety precaution adherence to be disclosed to my Employer or School. I expressly consent for On-Site Medical Services LLC. (“O-MS”) to share my personal information with Employer or School. 
I understand that O-MS and its agents are bound by data privacy laws and will never disclose identifiable information to any party without my express permission. I understand that I can, at any time, revoke my permission to provide my personal information to any party. I understand that I can ask for my information to be deleted at any time. I understand that all information stored on me can be downloaded by myself at any time. I understand that the use of Wellbility requires disclosure of personal information to Wellbility. I understand that if my information is subject to a subpoena or other lawful order that Wellbility must disclose my information. I understand that Wellbility, On-site Medical Services, and/ or any successors will advocate for the protection of my private information and will not comply with any data request from any party unless legally obligated. I understand that my information will never be shared with partner organizations, providers, or insurance groups without my express consent. I understand that I control how my data is used.
I understand and acknowledge that Wellbility does not diagnosis or treat any medical illness. I will not rely on Wellbility for medical advice or guidance. I understand that guidance provided by Wellbility is suggestive in nature and does not constitute a patient-physician relationship for purposes of reliance. I understand and acknowledge that given the unknown nature of COVID-19, it is not possible to fully list each and every individual risk of contracting COVID-19. I understand that Wellbility does not guarantee COVID-19 infection status, prevention of COVID-19, or ensure I am healthy. I understand that Wellbility cannot possibly prevent all chances of acquiring COVID-19.
I agree to provide personal information when using Wellbility candidly and honestly. I understand that erroneous or false information will result in my immediate termination from Wellbility. I agree to report to Wellbility any adverse employment consequences resulting from the use of any information provided to Wellbility; this includes but is not limited to disability discrimination, age discrimination, and adverse employment decisions. I understand that my Employer or School is prohibited from discriminating against me based on age or disability, and I will report to Wellbility any instances of discrimination. I agree to hold harmless O-MS, its physicians, as well as their respective officers, directors, employees and agents, from any and all claims, damages, losses, liabilities, costs and expenses, including attorney's fees, arising from or relating to Wellbility or disclosing information, including without limitation the disclosure of any inaccurate or incomplete results to the fullest extent permitted by law. This means I agree not to sue or hold responsible any such parties for any alleged harm, in any form, that might result from O-MS services.
I understand that O-MS is not responsible for any instances of discrimination or exclusion based upon medical data shared with third parties. I understand that O-MS is not responsible for any improper use of shared personal information. I release O-MS of all negligence related data management or lack thereof. I will hold no claims now or in the future against O-MS for any services or products utilized. I will not aid any claims or controversies against O-MS. I agree to hold O-MS harmless for any and all liability resulting from the use of any product or services provided by O-MS.
I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, even if arising from the negligence of the releasees or others. For myself and on behalf of my heirs, assigns, personal representatives and next of kin, I hereby release and hold harmless the O-MS, and its past, present, and future officers, directors, trustees, employees, attorneys, and agents, with respect to any and all illness, disability, death or damage to person or property associated with Wellbility, whether arising from the negligence of releasees or otherwise, to the fullest extent permitted by law. An employee’s right to seek workers compensation benefits will not be affected by this Agreement. I further agree that if any such claim is made, I will indemnify and defend the O-MS with respect to any such claim, with the exception of an employee’s right to seek workers compensation benefits.
I have read and fully understand the foregoing Agreement and I am aware that by agreeing to use Wellbility I may be waiving certain legal rights, including the right to sue. This Agreement shall be binding upon me and my heirs, legal representatives, and assigns, and shall inure to the benefit of the O-MS and its successors and assigns. I am voluntarily agreeing to use Wellbility. My use of Wellbility indicates that I am at least eighteen (18) years of age and intend to be legally bound by the terms of this Agreement.

603-826-6500

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Wellbility is owned and operated by On-site Medical Services LLC.

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