Covid-19 Antibody Testing Consent

Covid-19 Antibody Testing Consent
Test Information:

Detection of antibodies may indicate exposure to SARS-CoV-2 (COVID-19). It usually takes at least 5 days after symptom onset for IgM to reach detectable levels and 10 days for IgG. An IgM/IgG positive result may suggest an immune response to a primary infection with SARS-CoV-2, but the relationship between IgM/IgG positivity and immunity to SARS-CoV-2 has not yet been firmly established. Antibody tests have not been shown to definitively diagnose or exclude SARS-CoV-2 infection. (Source: Rapid and Quest Test Information)
Have you experienced any of these in the last 5 days?

High feverCoughDifficulty in breathingPersistent pain or pressure in the chestBody achesNasal congestionRunny noseSore throatPositive Covid-19 Diagnostic TestNone
Select one of the Covid-19 Antibody Tests to be performed:*

Rapid IgM/ IgG Covid-19 Antibody Cassette ( Results available in about 15 minutes)Serology Covid-19 IgG Antibody Lab Test (Results available in about 2-5 days)
Date of Birth*
Name*

First NameLast Name
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
I understand that the Covid-19 antibody test is solely a screening device that can detect IgM and IgG antibodies but the validity and reliability of the test is unknown due to the emergency authorization the FDA has permitted. Long term trials and studies have not been conducted to determine the long term validity of the antibody test.

I understand that the test results may be released to the Department of Health, FDA, CDC or Public Health Authorities.

I understand that the test results may be released to my employer.

I grant permission for my test results to be emailed to me at the email address provided above.

I have been offered a copy of the Notice of Privacy Practices.
By submitting I hereby confirm that the information I have given above is true, and that I will comply with the terms and conditions outlined above.
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