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  • COVID Test Request & Consent Form

    Western Upper Peninsula Regional Public Health Laboratory
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  • Consent for Testing

    Please read carefully. Submission of this form equals agreement with all terms.

  • a. I voluntarily consent and authorize Western UP Health Department 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, nasal swab, oral swab, or other recommended collection procedures.

    b.   I understand that I am not creating a patient relationship with the ordering physician by participating in this testing. I understand the entity performing the test is not acting as my medical provider. Testing does not replace treatment by my medical provider.

    c.  I assume complete and full responsibility to take appropriate action with regards to my test results and my medical care. I agree to seek medical advice, care, and treatment from my medical provider or other health care entity if I have questions or concerns, if I develop symptoms of COVID-19, or if my condition worsens. 

    d.   I understand that my test results will be disclosed to the appropriate public health authorities as is required by law.

    e.   I acknowledge that a negative test result is not a guarantee that I am not currently infected with COVID-19 and I may still need to be in isolation or quarantine.  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.

  • To the fullest extent permitted by law, I hereby release, discharge and hold harmless, Western Upper Peninsula Health Department, 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.

  • Authorization Form for Email Receipt of COVID-19 Test Results: {nameOf3}

    If you would like to have your COVID-19 lab report emailed to you, please read this form in its entirety and check the box below.

    By consenting to the use of email with Western Upper Peninsula Health Department (WUPHD), you agree that the Western UP Regional Laboratory may send you an email containing your COVID-19 Laboratory Test Report.

    When we send you an email, or you send us an email, the information that is sent or received may not be encrypted. This means a third party may be able to access the information and read it because it is transmitted over the Internet. In addition, once the email is received by you, anyone with access to your email account can read it.

    Western UP Health will use reasonable means to protect the privacy of your health information. However, because of the risks outlined above, WUPHD cannot guarantee that email will be confidential. Additionally, WUPHD will not be liable in the event that you or anyone else inappropriately uses or accesses your email. WUPHD will not be liable for improper disclosure of your health information that is not caused by WUPHD intentional misconduct.

    ACKNOWLEDGMENT
    By completing this form, I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communications of email between WUPHD and me, and consent to the conditions outlined herein, as well as any other instructions that WUPHD may impose to communicate with me by email. I understand that this consent is solely for the results of COVID-19 Testing performed at Western UP Health Department, by the Western UP Regional Public Health Laboratory.  I understand that this consent is valid for 90 days or until revoked.

    The laboratory has limited capacity to read emails sent from patients and you should not use email to communicate with WUPHD after receiving your results. If you need to speak to a provider concerning your results, please contact your healthcare provider directly.

    Prior to receiving your results, you will receive an email from regionallab@wuphd.org.  Please respond to this message with the requested information so we may confirm your identity prior to releasing test results to the provided email address.

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