COVID-19 Testing Consent Form

Today's Date

Month Day Year
Date
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Primary Care Physician
How would you like us to notify you of a negative test? A positive test will always receive a phone call.

Email Phone Call
Reason for Testing

Sick with Symptoms Close Contact (Within 6ft of COVID+ for > 15 mins.) Health Care Worker First Responder Long-Term Care Worker School Staff/Students Referred by Health Department Other
You selected "Other" for why you want a test. Please explain.
Worried well, work, travel, etc....
I understand my test results will be disclosed to the county and state health entities as requried by law. I acknowledge that a positive test result is an indication that I may by required to isolate to avoid infecting others and identify close contacts to the Health Department. I voluntarily consent to submit to a COVID test and have it analyzed. I also agree to allow the City/County Health Department to disclose my results to my employer if it is deemed necessarily to protect public safety.
Signature

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