Terms & Conditions

I acknowledge that I am voluntarily participating in the screenings and activities involved with the Breathing Triangle Screening form (“form”). My involvement is as a participant and not as a patient.

The medical professionals involved with the form are not my personal health care providers and are offering the screenings, self-care, information and activities solely as a voluntary educational program and are not offering or providing to me any treatment or diagnosis. I understand this means I do not have a provider-patient relationship with the medical professional.

If the medical professional(s) involved with the form identify potential concerns, the medical professional(s) may discuss their potential concerns with me on a purely informational basis. If I choose, I may follow up with the medical professional or another medical professional in addition to my primary care physician.

The screenings, self-care and information provided with the form do not constitute professional medical advice and are not a substitute for medical advice, diagnosis or treatment. I understand that I may need to follow up with either my primary care physician or a specialist regarding any recommendations that may be given to me after I am contacted by the medical professional(s), based on the answers from the form.

My employer and the medical professionals respect the confidentiality of the information I provide with the form. The parties involved with the form respect my privacy, but I understand that the information in this form is not considered part of a medical record and that information used or disclosed under this waiver may be disclosed by the recipient and may no longer be protected by federal or state law.

The information I provide will be used in the screening by the medical professional(s). I understand that no guarantees regarding screening results or prevention are being made. I hereby release the medical professional(s) and my employer from any responsibility whatsoever for unfavorable results or any injury, property damage or loss that may occur as a result of my participation with the form. I understand the terms and conditions above and am authorizing use of my health information in the way described above.