Covid 19 PCR Testing Appointment Form

COVID-19 PCR Testing

Appointment Form
Test results are usually available in 48 to 72 hours

The lab, MAWD, will contact you directly with test results
Thank you for choosing Kollhoff Pharmacy!

Please enter information below to schedule an appointment
Appointment*
Name*

First NameLast Name
Birth Day*

MonthDayYear
Guardian Name*

First NameLast Name
Guardian Birth Day*

MonthDayYear
Cell Phone Number*

Area CodePhone Number
Email*
example@example.com

INFORMED CONSENT FOR COVID-19 TESTING

1. Authorization and Consent for COVID-19 Diagnostic Testing:

·         I voluntarily consent and authorize the Kansas Department of Health and Environment (“KDHE”) to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test.

·         I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample through a nasopharyngeal swab, oral swab, or other recommended collection procedures.

·         I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and there may be a potential for false positive or false negative test results.

·         I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have questions or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider. I understand that I am not creating a patient relationship with KDHE by participating in this testing. I understand the testing unit is not acting as my medical provider.

2. Patient Rights and Privacy Practices

·         I acknowledge and agree that KDHE may disclose my test results and associated information to appropriate county, state, or other governmental and regulatory entities as may be permitted by law.

·         I acknowledge and agree that some limited personal information including my name and contact information may be shared with public health authorities if I am identified as a close contact to a positive case.

3. Release

·         To the fullest extent permitted by law, I hereby release, discharge and hold harmless, KDHE, including, without limitation, any its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results.

By providing my electronic signature to KDHE, I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I have been informed about the purpose of the COVID-19 diagnostic test, procedures to be performed, and potential risks and benefits. I have been provided an opportunity to ask questions before proceeding with a COVID-19 diagnostic test and I understand that if I do not wish to continue with the collection, testing, or analysis of a COVID-19 diagnostic test, I may decline to receive continued services. I have read the contents of this form in its entirety and voluntarily consent to undergo diagnostic testing for COVID-19.
Signature*

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After selecting "submit" you will be directed to a site to register for the test. Please save the confirmation code and give this to Kollhoff Pharmay staff when you arrive for your test.
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COVID-19 PCR Testing

Test results are usually available in 48 to 72 hours

Thank you for choosing Kollhoff Pharmacy!