1. Your Responsibilities. You acknowledge, represent, warrant and covenant to Atlantic Medical Clinic the following:
1.1 You are either (a) at least eighteen (18) years of age or (b) the parent or legal guardian of a person subject to Testing.
1.2 You understand that Test results reported by Atlantic Medical Clinic are based on the determination or diagnosis of the CareStar Antigen test performed on the Sophia Point of Care devices. These Test results will be reported directly to you via e-mail and/or phone call You further understand that it is your responsibility to consult your own medical professional for the interpretation, analysis, evaluation, and explanation of your Test results. You understand that Davies will not analyze, evaluate, critique, review, or otherwise interpret the Test results. It is your sole responsibility to seek and comply with necessary treatment and all required follow-up with your physician or local public health department.
1.3 You understand and agree that the service provided by Atlantic Medical Clinic and the Test results will be maintained as confidential, protected health information (“PHI”) by Atlantic Medical Clinic as required by federal and state law. You understand that the Test results will become part of your medical record. You understand an insurance company may discover the results of this Test by obtaining a copy of your medical record in accordance with the terms of your insurance policy(ies).
1.4 Regardless of the result of the Test, you agree and understand to follow and comply with all federal, state and local guidelines to reduce the transmission of COVID-19, including, but not limited to, the practice of social distancing, hand washing and sanitization, and the use of masks or face coverings. You agree and understand even with a negative COVID- 19 indication, you could still be contagious and will follow all recommendations.
2. COVID-19 Antigen Test Consent. You acknowledge, represent, warrant and covenant to Atlantic Medical Clinic the following:
2.1 You understand that this Test looks for the COVID-19 virus. You are electing to have this Test to assess whether or not you have been currently infected by the COVID-19 virus. Additionally, you understand that if you choose to have this Test outside the timeline guidelines for resolution of symptoms, the results may be less reliable. This Test does not guarantee immunity to COVID-19 or any other virus.
2.2 You also understand that the results of this Test may be given to the applicable local or state health authority or U.S. Centers for Disease Control for their statistical and demographic value.
2.3 Certain infectious diseases and conditions, and the identity of those who test positive for them, are required, by federal and/or state law, to be reported to local or state health authorities by your health care providers, including Atlantic Medical Clinic physicians, staff, or the laboratories (if any). The time frames and reporting requirements vary by authority. These local and state health authorities are considered Public Health Authorities under the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) which means they are legally authorized to receive your PHI. However, both Atlantic Medical Clinic will not otherwise share or release any PHI, unless mandated by law or authorized by you in writing.
2.4 You understand that if your Test returns positive for COVID-19, your Test result and your identifying information will be reported to the applicable local or state health authority. Reporting this information does not require your permission or consent. Additionally, you understand that if your Test returns positive for COVID-19, neither Atlantic Medical Clinic , nor its physicians, staff, or the laboratories (if any) that run the medical tests, will treat, prescribe medications, or refer you for medical treatment. It is your sole responsibility to seek and comply with necessary treatment and all required follow-up with your physician or local public health department.
3. Waiver. IN FURTHER CONSIDERATION OF BEING TESTED FOR THE PRESENCE OF COVID-19 THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING: THE UNDERSIGNED, ON HIS OR HER BEHALF HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE Davies, its owner(s), physicians, employees, volunteers and agents from all liability, claims, actions, damages, costs or expenses of any kind arising out of or relating COVID-19 testing to the undersigned and all personal representatives, assigns, heirs, and next of kin of the undersigned or such participating children for any loss or damage, and any claim or demands on account of any injury to, or an illness or the death of, the undersigned (or any person who may contract COVID-19, directly or indirectly, from the undersigned) whether caused by actions, omissions, or negligence of Davies or otherwise while the undersigned undergoes COVID-19 testing, this includes testing accuracy and reliability in testing included but not limited to false positive or false negative or otherwise inaccurate, un-interpreted, misinterpreted or results not received. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR, AND RISK OF ILLNESS, BODILY INJURY, OR DEATH in connection with accuracy and reliability in testing included but not limited to false positive or false negative or otherwise inaccurate, un-interpreted, misinterpreted or results not received. YOU ARE AWARE THAT BY AGREEING TO THIS AGREEMENT I AM GIVING UP VALUABLE LEGAL RIGHTS, INCLUDING THE RIGHT TO RECOVER DAMAGES FROM DAVIES IN CASE OF ILLNESS, INJURY, DEATH. YOU UNDERSTAND THAT THIS DOCUMENT IS A PROMISE NOT TO SUE AND A RELEASE OF AND INDEMNIFICATION FOR ALL CLAIMS.
4. Governing Law; Severability. This Consent shall be governed and construed in accordance with the laws of the State of Texas. If a provision of this Consent or any provision hereafter adopted shall for any reason be found to be inapplicable, invalid, illegal or unenforceable in any respect, such inapplicability, invalidity, illegality or unenforceability shall not affect the other provisions of this Consent, but the Consent shall be construed as if such provision had never been contained herein, or in the alternative, such provision shall be modified to the extent of such inapplicability, invalidity, illegality or other unenforceability.
5. Arbitration. Any dispute, claim or controversy arising out of or relating to this Consent or the breach, termination, enforcement, interpretation or validity thereof, including the determination of the scope or applicability of this agreement to arbitrate, shall be determined by arbitration in San Antonio, Texas before a single arbitrator agreed to by the parties. The arbitration shall be administered by the American Arbitration Association. Judgment on the arbitration award may be entered in any court having jurisdiction. This clause shall not preclude parties from seeking provisional remedies in aid of arbitration from a court of appropriate jurisdiction.
6. Counterparts and Electronic Signatures. This Consent may be executed in multiple counterparts (including electronic signatures, such as .PDF), each of which shall be deemed an original but all of which, when taken together, shall constitute one and the same instrument.
7. Result Delivery. The results will be delivered as soon as available from Atlantic Medical Clinic to the email and/or app and/or phone provided on the order form.