I hereby authorize Friendly Hills Pediatrics to perform collection and testing for exposure to SARS-COV-2 through a nasal swab as ordered by an authorized medical professional.
I understand that Friendly Hills Pediatric's laboratory is operating as permitted under applicable laws and regulations.
By signing, all parties agree to be contacted via telephone, text messaging, and patient portal.
I understand that if I receive a positive test result for myself or my dependent(s), I must ensure that I abide by all applicable local requirements with respect to isolation and quarantine to avoid infecting others.
I understand that testing does not replace treatment by a medical provider. I assume complete and full responsibility to take appropriate action with regards to the test result for myself and my dependents if applicable. I agree I will seek medical advice, care, and treatment from a medical provider for anyone who I am responsible for, if it becomes necessary.
I understand that, as with any medical test, there is the potential for false positive or false negative rest results to occur.
I understand that a copy of the privacy practices of this facility are found on the website friendlyhillspediatrics.com.
I understand that Friendly Hills Pediatrics may release information regarding treatment to third party payors such as Medi-Cal or insurance companies for the purpose of billing.
I understand that COVID-19 is a reportable condition. As such, Friendly Hills Pediatrics will report any positive cases including protected health information to the local health department.
I have been informed about the test purpose, procedures, possible benefits and risks. I have been given the opportunity to ask questions before I consent.
I voluntarily agree to testing for COVID-19 for myself and if applicable, my dependent(s).
I further understand the testing fees are due and payable on the date that services are rendered and agree to pay all such charges incurred at the time of the visit.
I have read and understand all the above statements and agree to uphold the terms and conditions of the above policies of Friendly Hills Pediatrics.