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Spring 2021
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COVID-19 Test Informed Consent Release Form

Saint Vincent College/PCMA Network
Please carefully read and sign the following Informed Consent
1. I authorize the PCMA Network COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab.
2. I understand the collection procedure and possible risks:
  1. A thin cotton tip applicator is passed into both anterior nares (nostrils).
  2. The test may be briefly uncomfortable.
  3. Some bleeding after the collection may occur, but is not expected
  4. Failure to obtain an adequate specimen may result in inaccurate or inconclusive test results.
3. I authorize my test results to be disclosed to the Saint Vincent College for the purpose of contact tracing and disease mitigation. Test results will be held to the highest standards of confidentiality.
4. I understand that, in the event of a positive result, I will be contacted by the Saint Vincent College Wellness Center regarding isolation and contact tracing and that the result will be released to county, state, or other governmental entity as may be required by law.
5. I acknowledge that a positive test result is an indication that I must self-isolate (at home or on campus, decided in consultation with Saint Vincent College) until I am cleared by Saint Vincent College to leave isolation.
6. 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 that I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.
7. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.
I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I will receive 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 understand that before signing this document I may consult with others, including my personal physician and that by signing it I represent that I have either done so or decline to do so.

I voluntarily agree to this testing for COVID-19.

I have read and I understand the acknowledgements set forth above, and I hereby release PCMA and Saint Vincent College and their affiliated entities, and all of their agents, employees, trustees, and representatives, from any and all liability which may arise from the testing process and/or from the information provided to me concerning such testing. I understand the benefits and risks of COVID-19 testing and consent as described above.

I affirmatively represent to Saint Vincent College that I am 18 years of age or older and am fully competent to execute this Informed Consent Release Form. .
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COVID-19 Test Informed Consent Release Form