Cue Molecular COVID-19 Testing

Uinta County Public Health Consent for COVID-19 Testing
Uinta County Public Health utilizes the Cue Molecular COVID19 testing platform.

The Cue COVID-19 Test is a U.S. FDA Emergency Use Authorized molecular nucleic acid amplification test (NAAT) that detects the genetic material of SARS-CoV-2 using a molecular amplification reaction that is an equivalent amplification method to molecular polymerase chain reaction (PCR).

Please complete the consent & questionnaire below.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Email
example@example.com
Address *

Street Address

Street Address Line 2

City
Phone Number *

Area Code Phone Number
How would you like to receive test results? *

Email Text
If results by email how do you want them to come?

Encrypted Not encrypted
Sex

Male Female
Race

Asian Black Native American Pacific Islander White
Ethnicity

Hispanic Non Hispanic
Are you a healthcare worker?

No Yes
Are you a resident of a long-term care facility?

No Yes
Are you currently pregnant?

No Yes Prefer not to answer
Any symptoms?

None Fever > 100.4 Feeling Feverish Chills Fatigue Cough Shortness of Breath Difficulty Breathing Headache Muscle or Body Aches Sore Throat Nasal Congestion Runny Nose New Loss of Taste New Loss of Smell Nausea Vomiting Diarrhea
Symptom Onset Date:

Month Day Year
Date
Are you seeking testing for travel?

No Yes
Consent & Privacy Practices Information:

I give my consent for the services that I am requesting from the Uinta County Public Health Nursing staff and its representatives to render routine health care to myself or my child. I understand that routine health care is confidential and voluntary, and that I may discontinue services at any time.

I understand that the risks and benefits for these services will be explained to me and that I will have the opportunity to ask questions.

I understand that the information regarding myself and the services I receive may be entered into a management information system and may be used for program evaluation, management, and billing purposes. However, my name will not be released without my written permission.

In accordance with state reporting laws, reportable disease(s) will be reported to the appropriate Wyoming Department of Health authorities.

If the client is a minor, the client’s parent or guardian must sign. If client is a minor, but is signing for their own services, please complete the Minor as a Client form (PHN-F-354).
Acknowledgement of Receipt of Notice of Privacy Practices

The Notice of Privacy Practices describes how the Wyoming Department of Health (WDH) may use or disclose information. Not all situations may be described. WDH is required to furnish its clients with a notice of privacy practices pertaining to information we use, maintain, and disclose. Please click here to view the Notice of Privacy Practices.
Initials (Client’s initials)
I have received a copy of the WDH Notice of Privacy Practices and have had an opportunity to ask questions regarding how my information will be used.
Signature of Patient or Parent/Guardian *

Clear
Name of the person who signed above

First Name Last Name
Relationship of consenter to client: *
Schedule Your COVID-19 Cue Test Appointment
You will stay in your car for testing.

At your scheduled time, please pull up to the door at 350 City View Drive, on the west side (the old LUCDA, and the door facing YAHA.)

We will be watching for you, but if no one comes out, please honk.
Special Notes or Requests
Should be Empty:

Uinta County Public Health Consent for COVID-19 Testing