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 a third party laboratory. 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 feverCoughDifficulty in breathingPersistent pain or pressure in the chestBody achesNasal congestionRunny noseSore throatPotential exposure to Covid-19None
Have you experienced any of these in the last 5 days?

High feverCoughDifficulty in breathingPersistent pain or pressure in the chestBody achesNasal congestionRunny NoseSore throatPotential exposure to Covid-19None
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 NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / 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. A third party laboratory 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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