Request Form

Step 1 of 2

Personal Particulars

Specimen ID *

Chinese Name of the Participant

English Name of the Participant *

First

Last

Sex *

Male
Female

Date of Birth *

Specimen Collection Date *

Contact Phone Number *

Email Address *

Postal Address *

Consent Form Consent Form

I object to the proposed use of my personal data for the above-mentioned promotion purposes.

I authorize WellMind BioMed Technology Holdings Limited (WellMind) to conduct laboratory testing for the Autism Spectrum Disorder (ASD) Genetic Based Risk Assessment for the client specified in the request form, and authorize the collection of sample(s) for the purpose of these tests, and am entitled to the protection of the Personal Data (Privacy) Ordinance 1. I acknowledge and consent to the following:
1. I understand that the analysis of test results may be affected by the personal details (e.g. gender, age, ethnicity, etc.) provided. Therefore, it is my responsibility to provide complete, correct and up-to-date personal information.
2. I understand the purpose, meaning, procedure, nature of the test(s), their potential use(s), limitations in test accuracy, and any medical risks inflicted. I understand that the test results and data are for reference purpose only and do not provide any clinical diagnosis which shall be carried out by a physician only.
3. I have been given the opportunity to raise questions, and I have been told that I can ask any questions at any time.
4. I understand that the collected sample might occasionally not be suitable for testing due to non-compliance with the sample collection guidelines or other reasons, and therefore we may need to obtain a new sample (free of charge) to conduct the agreed testing. However, if I refuse to provide the new sample, there will be no refund.
5. I understand that any remaining samples will be retained by WellMind for internal use.

1 WellMind BioMed Technology Holdings Limited (WellMind) undertakes to comply with the requirements of the Personal Data (Privacy) Ordinance to ensure that the personal data kept are accurate and securely kept. To safeguard the interest of our clients, WellMind collects personal data from you for the purposes of this test request, and may use your personal data (name, telephone number, email, and postal addresses) for the purposes of providing you with further information, communication, invitation to activities/seminars, as well as to collect feedback and/or related promotion. Upon your request at any time and at no charge, we will cease to use your personal data for promotion purposes. You may contact us at +852 3613 0107 (WhatsApp 5605 6721) for enquiry or updating your personal data. Should you wish to opt-out from the above-mentioned use of your personal data, please tick the box below.