COVID-19 (SARS Antigen &/or PCR) Test Consent Form

COVID-19 (SARS Antigen &/or PCR) Test Consent Form
First Name
Middle Initial
Last Name
Date of Birth
Age
Gender

MaleFemale
Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Home Phone:
Cell Phone:
SS#:
Ethnicity

Hispanic or LatinoNon-Hispanic or Latino
Race:

American Indian or Alaska NativeAsianBlack or African AmericanCaucasianHispanic, Latino, or SpanishNative Hawaiian or Pacific IslanderOther
Email address:
example@example.com
Primary Physician:
How would you like to be notified of results?

EmailText MessageBoth Email & Text Message (recommended)
Do you have health insurance? (Insurance will be billed for PCR test only)

YesNo
Insurance (only needed for PCR test)
Policy #
Group #
Employer/School/Organization
I request my results to be shared:

YesNo
Send results to:

Primary PhysicianEmployerSchoolOrganization
Have you traveled outside of Texas in the last 14 days?

YesNo
If so, to what location?
In the past 14 days , have you had direct contact with someone who is confirmed to have COVID19 or is presumed to have COVID -19?

YesNoNot Sure
Date of Contact

MonthDayYear
Date
If so, what type of contact?

Living in the same householdCo-WorkerSchoolAttended the same functionOther
Are you employed in Healthcare?

YesNo
Hospital

YesNo
Are you a resident in a congregate care setting (nursing home, group home, foster care or other setting)?

YesNo
COVID 19 Screening Questions

People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. The average is 5-6 days. People with these symptoms may have COVID-19:
Do you have a fever or chills?

YesNo
Do you have a new onset cough?

YesNo
Do you have shortness of breath or difficulty breathing?

YesNo
Shortness of Breath or Difficulty Breathing

MildModerateSevere
Do you have a sore throat/Hoarseness?

YesNo
Do you feel fatigued?

YesNo
Do you have muscle or body aches?

YesNo
Do you have a headache?

YesNo
Have you had a new loss of taste or smell?

YesNo
Are you congested or have a runny nose?

YesNo
Do you have gastrointestinal symptoms of nausea, vomiting or diarrhea?

YesNo
Onset of symptoms

MonthDayYear
Date
No Symptoms

No Symptoms
Have you been tested for COVID-19 within the last 30 days?

YesNo
Previous COVID-19 Test type

MolecularAntigenAntibodyUnknown
Are you pregnant?

YesNo
Have you received a COVID-19 Vaccine?

YesNo
I reviewed a copy of the Fact Sheet for Patients for the BD Veritor System for Rapid Detection of SARS-CoV-2 and the Thermo Fisher Scientific, TaqPath™COVID-19 Combo Kit & TaqPath™COVID-19 Combo Kit Advanced and have had the opportunity to ask questions about the risks and benefits of this test.

YesNo
I consent to being tested for COVID 19/Flu by Valmed Home Health & Pharmacy Solutions, which is a nasal swab and/or nasopharyngeal swab. Every lab test has the slight risk of a false negative or a false positive. The U.S. FDA has made the COVID 19 test available for use under an emergency access mechanism called an Emergency Use Authorization (EUA). I hereby waive any liability towards Valmed Home Health & Pharmacy Solutions and/or its administering employee of a potential false positive or false negative result. I authorize the release of the results of the test and medical information necessary to my healthcare provider listed, if requested. I understand that my results may be reported to State & Local Departments of Health while maintaining my privacy. I have been offered the HIPAA Privacy Policy. I understand that I may present my receipt to my third-party payor and that they may not cover the testing and I agree to pay for services rendered.
Signature of Person receiving test or Parent or Guardian

Clear
Date

MonthDayYear
Date
Relationship
( If Minor or unable to sign)
Should be Empty:

COVID-19 (SARS Antigen &/or PCR) Test Consent Form

COVID 19 Screening Questions