COVID Outreach Wood River

Name *

First Name Last Name

Gender *

Female Male Unspecified

Date Of Birth *

Month Day Year

Street Address (does not have to be mailing address) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

Email (Necessary to receive a copy of results. We phone results either way.)

example@example.com

Primary Physician

Are you a student or a teacher? *

Student Teacher I am neither

Have you EVER had a COVID PCR nasal test, regardless of result? *

Yes No

Have you had a POSITIVE result for a COVID nasal test in the last 3 months? *

Yes No

Are you a healthcare worker? *

Yes No

Have you been hospitalized due to COVID-19 recently? *

Yes No

Have been a patient in an Intensive Care Unit due to COVID-19 recently? *

Yes No

Do you live in any congregate housing such as a dormitory or shelter? *

Yes No

Are you pregnant? *

Yes No

By clicking yes, you are agreeing to give honest answers to this questionnaire and that you've read and agreed to our terms and conditions . *

I agree

COVID Outreach Wood River

Informed Consent for Coronavirus (COVID-19) Testing

Please carefully read and sign the following informed consent:

1. I authorize this COVID Outreach Wood River to conduct collection and testing for COVID-19 through a nasal swab with FDA Emergency Use Authorization.

2. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.

3. I authorize transmission of my test result to me via digital means.

4. I understand that COVID Outreach Wood River will not send my results to anyone other than the district and state health department as required and to my primary care physician if listed. If I want my result sent to anyone else, including an employer or school, it is my responsibility to do so. It is my responsibility to check with any outside entity requiring a test regarding their requirements, including facilities and destinations.

5. I acknowledge that a positive test result is an indication that I must continue to self-isolate in an effort to avoid infecting others, per CDC guidelines. I understand that self-isolating/quartanting may impact my employment.

6. I understand that, as with any medical test, there is the potential for false positive or false negative test results to occur.

7. I understand that a negative test result does not rule out COVID-19 infection, that I assume full responsibility for following CDC guidelines regarding self-isolation following close contact exposure, and that a negative COVID19 viral detection test does not end my self-isolation prior to CDC guidelines (14 days after exposure).

8. I understand that COVID Outreach Wood River is not establishing a physician-patient relationship and is not acting as my medical provider. This does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree that I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.

9. I understand that this test sample collection requires that testing staff insert a swab into my nose, rotate it for 3-5 seconds, and repeat on the other side of my nose and that I may experience pain, the urge to sneeze or cough, or light bleeding.

10. To the fullest extent permitted by law, I hereby release, discharge and hold harmless, COVID Outreach Wood River, including, without limitation, any its respective officers, directors, employees, representatives, donors, 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.

I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask other questions at any time. I voluntarily agree to testing for COVID-19.

Signature of individual being tested *

Clear

Parent Name, if signing for a minor being tested.

First Name Last Name

If the individual being tested is a minor, Parent Signature required here:

Clear

Triage: COVID Outreach Wood River

IMPORTANT:

COVID-19 Informed Consent, Liability Waiver

Symptoms

Symptom Onset Period

Date of Symptom Onset

Exposure to Close Contact?

Exposure Timeframe

Date of Exposure

Pre-surgical or pre-procedural testing

Travel testing or visiting from out of town?

These tests represent an important public resource and generous gift to the community.