Kirby Consent COVID (Non-Members)

COVID PCR

Informed Consent, Financial Policy Agreement, and Acknowledgement of Notice of Privacy Practices

I authorize The Vine Pediatrics and Lactation PLLC ("Practice") to perform a COVID-19 PCR Test on myself or my child on a date to be determined.

I understand that I am a self-pay patient, and I will be responsible for paying for any services received. These fees will not be billed to my insurance company because The Vine Pediatrics and Lactation PLLC does not submit claims to insurance and does not bill insurance.

I acknowledge that the fee is a monetary payment for one test, and payment must be sent by Zelle (info@vinepediatrics.com) or Paypal (info@vinepediatrics.com). Payment is due prior to any services received. I will receive a PDF document report by email which will include receipt of payment, result of the test, and recommendations within 24 hours of the test. I consent to receive the test results at an email address that I will provide below. The email I receive may come from an unencrypted email server which may be unsecure.

I understand that the The Vine Pediatrics and Lactation PLLC reports all positive test results to the Harris County Public Health Department.

I understand that I am not a member of the The Vine Pediatrics and Lactation PLLC. I understand that the Practice does not offer medical advice beyond what is written on the report for non-members and does not provide medical treatment for non-members of the practice. I understand that I must follow-up with my own physician regarding medical advice, care, or treatment pertaining to my test results. I will not hold the Practice, Dr. Sharifa Glass, or the Practice's staff liable for adverse reactions, progression of illness, or future illness.

I understand that the test result should not be used in place of CDC recommendations to social distance, wear a mask, and wash hands to decrease transmission of COVID-19 and other infections.

By signing below, I acknowledge that The Vine Pediatrics and Lactation has made the Notice of Privacy Practices available to me prior to any services being provided to me by the Practice. I consent to the use and disclosure of my medical information as set forth herein in the Notice. This includes authorization to enter personal and medical information into my electronic health records.

By signing below, I consent to receive a COVID PCR Test administered by The Vine Pediatrics and Lactation PLLC on a date to be determined.

BY SIGNING THIS FORM, I CERTIFY:

• That I have read or had this form read and/or had this form explained to me.
• I have the legal right to consent because I am the patient or I am the parent/guardian of the patient. All references to "patient", "me" and "my" in this document means:

Patient Name*

Patient Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County*

Phone Number*

Please enter a valid phone number.

Sex/Gender (Required by Harris County Public Health. We welcome people of all gender identities)*

MaleFemale

Race*

Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoUnknown

Reason for Test*

TravelSymptoms consistent or concerning for COVID19 illnessExposure (we recommend unvaccinated persons to test at day #7 post exposure if they do not have symptoms)College/University/Dorm RequirementPre-Surgery TestOther

Email Address to receive results*

example@example.com

Name of Patient Representative*

Signature of Patient Representative*

Relationship to Patient*

Date of Signature*

Date

The Vine Pediatrics and Lactation PLLC
8990 Kirby Drive

Suite 220

Houston, Texas 77054
832-802-4920 (phone)
832-336-3947 (fax)
www.vinepediatrics.com