Covid-19 Diagnostic Testing Consent

Covid-19 Diagnostic Testing Consent
COVID-19 Saliva Diagnostic Test Information:

A lab developed saliva-based molecular test that is easily self-collected and shipped to the CRL lab. Results of the test confirm if the virus is detected in the saliva of the individual.

Your result will be delivered directly to you via phone – mobile or landline – as soon as it is available (approximately 48 hours). If you provided a telephone number during registration, you will be contacted via text or voice message when the result is available. Before viewing the result online, you will be prompted to complete a dual factor authentication process.

Molecular results to determine active virus are reported detected (positive) or non-detected (negative). Molecular testing provides evidence of an active, or recent infection. The molecular test does not provide a quantitative level of the virus or indicate the severity of the infection.
Have you experienced any of these in the last 5 days?

High fever Cough Difficulty in breathing Persistent pain or pressure in the chest Body aches Nasal congestion Runny nose Sore throat Potential exposure to Covid-19 None
Have you experienced any of these in the last 5 days?

High fever Cough Difficulty in breathing Persistent pain or pressure in the chest Body aches Nasal congestion Runny Nose Sore throat Potential exposure to Covid-19 None
Covid-19 Diagnostic test to be performed: *

Covid-19 Saliva Diagnostic Lab Test (Results available in about 2-5 days)
Date of Birth *
Employee ID Number
Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Test notifications may be texted
I understand that All For Life is solely functioning as the facilitator of the collection and submitting my specimen to the lab. The CRL lab and their physician are responsible for the molecular test and reporting the results to the donor and applicable agencies.

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 sent via text, emailed to me at the email address provided above or communicated via the phone.

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.
Signature *

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