COVID-19 Antigen or PCR Testing Consent

Name*

First NameMiddle InitialLast Name

Date of Birth*

Date

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

County*

Gender*

MaleFemaleOtherUnknown

Ethnicity*

HispanicNon-HispanicUnknown

Race*

Reason for Testing*

Contact with COVID-19, suspected exposureHaving symptoms, such as cough, sore throat, loss of smell/taste, etc.Asymptomatic, no known exposure; for screening purposes onlyPossible exposure to COVID-19

Do you have any known drug allergies?*

YesNo

If you have known drug allergies, please list them.

Email (optional)

example@example.com

Passport ID (optional)

Please carefully read and sign the following Informed Consent:

A. I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab or blood draw, as ordered by an authorized medical provider or public health official.

B. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.

C. I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others.

D. I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care, and treatment from my medical provider if I have questions or concerns, or if my condition worsens.

E. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.

F. I understand and agree that I am financially responsible for all charges for any and all services rendered. This includes any medical service or visit, testing, and any other screening ordered by the provider or staff.

G. I understand that while my insurance may confirm my benefits, confirmation of benefits is not a guarantee of payment and that I am responsible for any unpaid balance.

H. If I am a Medicare patient, I understand that I need to provide the office with both my Medicare ID card and my secondary ID card. If the office does not have the proper information for secondary insurance, the secondary will not be billed. It will be my responsibility to pay the balance and then file a claim with the secondary for reimbursement.

I. By signing this form, I consent to the use and disclosure of protected health information about me for treatment, payment, and health care operations, and/or as required by law. I have the right to revoke this Consent, in writing, signed by me. However, such revocation shall not affect any disclosures already made in compliance with my prior Consent. Better Health Pharmacy's notice of privacy practices can be found at www.betterhealthfw.com/forms.

I, the undersigned, have been informed about the test purpose, procedures, possible benefits, and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.

Name of Patient*

Full Name of Patient

Signature of Patient or Guardian*

Date*

Date

If you have signed this form as a legally authorized representative of the patient, please identify your relationship to the patient below. (parent, guardian, etc.)