TEST SCREENING WAIVER / EXENCION DE PANTALLA DE PRUEBA
This consent provides TYDUS GROUP, and its subsidiaries (“BRIGHTSIDE SPECIALTY PHARMACY”) with your permission to perform an Accula SARS-COV-2 PCR Test based on TYDUS GROUP’s policies and procedures.
By signing below, you are indicating that you voluntarily consent to this procedure for the detection of COVID-19.
The Accula SARS-COV-2 PCR Test being administered involves a nasal swab to obtain a sample which will then be tested for the presence of SARS-COV-2 that may indicate the presence of COVID-19. You will be required to stay in a designated area pending results of the test, and based on the results, you may not be allowed to enter the pharmacy.
The Accula SARS-COV-2 PCR Test has been allowed for use by the Food and Drug Administration (“FDA”) but has not been approved by the FDA. This test alone may not be sufficient to detect or rule out the possibility that you have been exposed to or are infected with COVID-19. You should carefully monitor your own symptoms and, notwithstanding the results of any testing, you must stay home and consult with your physician if you experience symptoms of COVID-19.
You have the right to discuss the proposed testing with your physician, to learn about the purpose, potential risks and benefits of any testing.
By signing below, you consent to the disclosure of such information as requested, recommended or required by federal, state, and local public health authorities.
Personal Information Privacy and Use of Results. TYDUS GROUP will not receive your individual named sample or results from this test and will not retain any right to test your sample for any purpose other than determining if you tested positive for SARS-CoV-2. Under no circumstance will any personal information be made available to, or disclosed by, TYDUS GROUP, with the exception of this Consent Form.
By signing below, you agree to release and waive any claim arising from your selection to receive this screening, that may arise against TYDUS GROUP and its designated medical providers and staff members. In addition, by signing below, you acknowledge that any testing that may be performed for Accula SARS-COV-2 PCR has not been approved by the Food and Drug Administration (FDA). Accordingly, you agree to release and waive any claim that might arise against TYDUS GROUP and its designated medical providers and staff members for any risks, side effects, or complications resulting from the testing.