By signing below, I understand and agree that:
1. I have asked to receive the COVID-19 antigen test and that I am age 18 or over or am the legal parent/guardian of the minor listed above. *Patients under the age of 18 must be accompanied by a parent or legal guardian.
2. The above test is a qualitative test that detects the presence of the SARS-CoV-2 virus.
3. The pharmacist's consultation with me about the test results does not constitute medical advice.
4. The data derived from the test is considered preliminary and is not conclusive as to the absence or presence of any disease or health condition.
5. Altitude Drug LLC recommends that I report the results of the test to my healthcare professional so she or he can help me determine whether I need followup care. Altitude Drug will report the results to the Wyoming Department of Health.
6. The responsibility for seeking followup medical advice regarding the test result is mine and not that of any organization or professional associated with the test.
7.I understand that Altitude Drug will not submit a claim to any insurer for the test given to me. The cost of the testing is my personal responsibility and must be paid prior to testing.
8. I understand Altitude Drug is bound by HIPAA to protect my privacy, but that results may be shared with providers, public health officials, and authorities such as state and federal government agencies as appropriate for study of the current worldwide pandemic.
9. In consideration for undergoing the test, I hereby release and hold harmless Altitude Drug and their respective owners, directors, officers, and employees from any liability arising from the testing.
10. By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature and that it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.