2023 Covid-19 Intake Forms-Juneau

Give your consent

(Please check every paragraph to confirm consent.)
I consent to testing and laboratory analysis by MedPhysicals Plus, LLC. My results and the information provided by me may be reported to the ordering physician, the person or entity arranging this testing (which may include, without limitation, a current or prospective employer), any of my or their designees, and public health authorities in accordance with applicable law. I consent to receiving email, text messages, and phone calls at the email address and phone number provided by me. My results may be reported to me through any of the foregoing means or any other reasonable mechanism, including web-based applications, at any time as my results are available. Any results I receive are for informational purposes only and do not constitute a medical diagnosis. It is my sole responsibility to seek and obtain medical and other advice relating to this testing and any results I receive. I consent to my information and results being shared with providers of the Physician Services.*

I AGREE
I understand that there are possible risks associated with blood draws, saliva and nasopharyngeal swab specimen collection, including, without limitation, infection, discomfort, and bruising. I understand these risks may not be all-inclusive and that other more remote risks may be involved. As with all laboratory tests, there is a chance of a false positive or false negative result. By initialing, I am agreeing to all of the terms of this Notice, Consent, and Release for COVID-19 Testing. To the fullest extent permitted by law, I release and forever discharge MedPhysicals Plus, LLC and the laboratories they employ to perform the testing and analysis and the person or entity arranging this testing from liability relating to the Physician Services and the collection, testing, and reporting of information described herein.*

I AGREE
MedPhysicals Plus, LLC requires payment at the time of service and by signing below I agree that I am financially responsible for all services I may acquire from my visit(s). I acknowledge that MedPhysicals Plus does not bill any health insurances. I understand that a detected/positive test DOES NOT mean that I am immune to COVID-19 and that I will never catch the virus again. In consideration for such services being rendered on my behalf, I hereby RELEASE MPP, its officers, agents, and employees, from any and all claims which I might otherwise have due to such results being made so available. I hereby CONSENT NOT TO FILE ANY ACTION at law or in equity against company connection with the results of such screen being made so available, and I herby agree to INDEMNIFY and SAVE HARMLESS MedPhysicals Plus, LLC, the laboratory testing service, their respective officers, agents, and employees from all damages, expenses, reasonable attorney's fees, and costs of court which they or any of them may suffer or incur, jointly or severally, due to the results of such screen being made so available.*

I AGREE
I am at least of 18 years of age or the legal guardian of the donor with authority to consent on their behalf. I AGREE TO ALL OF THE TERMS OF THIS NOTICE, CONSENT AND RELEASE FOR COVID-19 TESTING.*

I AGREE
Only check if the following statement pertains to your visit today
TESTING FOR TRAVEL PURPOSES: I understand that it is my sole responsibility, as the traveler and client, to research which COVID-19 test is required for where I am traveling to. I understand that MedPhysicals Plus, LLC will conduct the COVID-19 testing that I request. I acknowledge that Lab-based tests can take up to 96 hours and MedPhysicals does not guarantee that the result report will be sent sooner than 96 hours. By signing below, I release the right to a refund if I, the client, order the wrong test or have the test completed outside of the required time limit for the places I am traveling to.

I AGREE
If traveling and if needed for entry in your travel destination, please list passport number. (How you type it here will auto populate on your Result Report. PLEASE DOUBLE CHECK!) We will be confirming your identity when you come in for testing. Please bring your passport or government-issued I.D. We will be writing down the type of ID and number that you present to us. Please be advised that most countries require the passport # on the result form.
(If traveling) Country of passport origin
(If traveling) Please list country you are traveling to
Panabios ID (if applicable, for Trusted Travel Program; for travel to Africa)
CONSENT TO RELEASE RESULT TO EMPLOYER

I AGREE
I give consent for my result to be released to (name of Employer or Individual)
Signature*

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Covid-19 Intake Form

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