PATIENT ACKNOWLEDGEMENT & CONSENT TO COVID−19 TESTING
1. I voluntarily consent to the collection and submission of my specimen to Select Reference Laboratories, LLC, an out−of−state clinical laboratory (the “Lab”), for purposes of a COVID−19 diagnostic test (“COVID−19 Test”).
2. The specimen being submitted for a COVID−19 Test is my own. I have not adulterated the specimen in any way.
3. I acknowledge that my specimen is being collected pursuant to the terms of a standing order issued by Lela E. Dougherty, M.D., a [physician/nurse practitioner] licensed in the [State/Commonwealth] of Pennsylvania (the “Ordering Practitioner”). The Ordering Practitioner may be contacted as follows:
Lela E. Dougherty, MD
4284 William Flynn Hwy, Suite 102, Allison Park, PA 15101
412-685-3373
Lela@NavusHealth.com