Sample-Attestation

ATTESTATION OF VACCINE STATUS

I attest that I have not received any dose(s) of a COVID vaccine, MRNA or otherwise. I further attest that I do not plan to receive a COVID vaccine.

I consent to allowing Unjected and tele-medicine partner The Wellness Company to request my state vaccination record to confirm my status.

I agree that if I change my mind and decide, for whatever reason, to receive a COVID vaccine, I will alert Unjected and voluntarily revoke my Verified status.

By completing this attestation, I agree to sharing my non-vaccinated medical status with other members of Unjected community.

I understand that falsifying this attestation may amount to sexual misconduct in certain jurisdictions, and Unjected may have a duty to warn other users if a falsification is found.

* Yes No

AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I request that my protected health information regarding my care and treatment be released as set forth on this form.

I understand that I authorize The Wellness Company and its third-party contractors or affiliates to retrieve and disclose my health record and protected health information (PHI) to The Wellness Company. I understand the health records retrieved may not be a complete 100% comprehensive record, and these records may not be useful for diagnostic purposes. These health records will be shared with The Wellness Company Authorized Providers to ensure great healthcare services.

I understand and request that the following information may be retrieved and disclosed with my The Wellness Company:
• Available medical record history (including available records from prior providers)
• Evaluation records and patient summaries
• x-ray reports
• Laboratory reports
• Hospital records and reports
• Immunizations
• Prescription data
• Consultation documents
• Surgical reports

* Yes No

I acknowledge that I have read and understand the above disclaimer.

* Yes No

I confirm that:
1. I am providing current, complete, and accurate information;
2. I agree to the authorization for the use and disclosure of protected health information.
3. I agree to Unjected's Terms and Conditions and Privacy Policy *

* Yes No