Loading...

Please read this form in its entirety and sign below when finished. 

If you do not see a response email from us in your inbox, PLEASE check your spam or junk folders!  Thank you 



Our office follows all HIPAA guidelines. Your information is private and will not be shared with anyone outside of our office without a written consent from you.

In consideration of the risk of possible injury and safety that exists while participating in the Natural Acquired COVID Immunity Passport (hereinafter the "Activity"); and

In consideration of my participation in the foregoing, the undersigned acknowledge and agree to the following;

I am aware that the purpose of this website is to provide people with the knowledge of their natural acquired immunity and immunity status with or without receiving the COVID vaccine.

I am fully and personally responsible for my own safety, and actions while during my participation with the Acquired COVID Immunity Passport, and I recognize that not all facilities such as, but not limited to, bars, restaurants, stores, shopping centers, venues, offices, etc. may not participate or accept this Acquired COVID Immunity Passport. 

I acknowledge that releasees are not responsible for errors, omissions, acts, or failures to act of any party or entity

I acknowledge that just because I may have the natural immunity antibodies does not mean I can not get the COVID-19 virus again.

I acknowledge that there is no personal or financial relationship between us and Labcorp, and that there may be additional charges from Labcorp after blood work is drawn.

I agree that this doctor-patient relationship is limited only to providing access to blood testing and the results. Our follow up is limited to providing you your test results as reported by Labcorp only. I agree to provide and respond with honest answers to this website and emails. 

With full knowledge of the risks involved, I hereby release, waive, discharge the authors, providers of Natural Acquired COVID Immunity Passport, its board, officers, affiliate's, employees, successors, representatives, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury or death, that may be related to the use of the Acquired COVID Immunity Passport.

I agree to indemnify, defend, and hold harmless the authors/ provider, affiliates, employees of this website from and against any and all costs, expenses, damages, lawsuits, and or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to but not limited to injury, loss, or death from or related to the Natural Acquired COVID Immunity Passport and its opinions.  

I hereby acknowledge that I have carefully read this "waiver and release" and fully understand that it is a release of Liability. I expressly agree to release and discharge the Acquired COVID Immunity Passport and all of its affiliates, managers, members, agents, attorneys, staff, volunteers, Heirs, representatives, predecessors, successors, and assigns, from any and all claims or causes of action, and I agree to voluntarily give up or waive any rights that I otherwise have to bring a legal action against the authors/ provider of the "Natural Acquired COVID Immunity Passport" for, but not limited to personal  injury, property damage, death, etc.

This waiver and release of liability shall remain in effect for the duration of my participation in the activity during this initial and all subsequent events of participation.

I acknowledge that I had the opportunity to email or contact the website and ask any questions regarding any issues or concerns I have about the testing, and I have full knowledge of what I am doing.

I understand that this doctor issued passport has no affiliation with the CDC COVID passport. 

I agree that all information on this waiver form is correct and accurate. 

 


Please check the following appropriate box
Vaccination Status *
Not Vaccinated
Vaccinated
Vaccinated with boosters
What type of vaccine did you receive
Click all that apply
Moderna
Pfizer
Johnson & Johnson
Astrazeneca
None of the above
First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!