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Coronavirus Testing Form - Individuals
Coronavirus Testing Form - Individuals
Hi there, please fill out and submit this form.
22Questions
Coronavirus Testing Form - Individuals
  • 1
    Click "Yes" if you are giving this test to your child and filling this form out on their behalf. Otherwise, click "No."
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  • 2
    The name of the person filling out this form on behalf of a minor child.
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  • 3
    This should be your name or the name of a minor child you giving the test to.
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  • 4
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  • 5
    Pick a Date
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  • 6
    Please Select
    • Please Select
    • Alabama
    • Alaska
    • Arizona
    • Arkansas
    • California
    • Colorado
    • Connecticut
    • Delaware
    • District of Columbia
    • Florida
    • Georgia
    • Hawaii
    • Idaho
    • Illinois
    • Indiana
    • Iowa
    • Kansas
    • Kentucky
    • Louisiana
    • Maine
    • Maryland
    • Massachusetts
    • Michigan
    • Minnesota
    • Mississippi
    • Missouri
    • Montana
    • Nebraska
    • Nevada
    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Ohio
    • Oklahoma
    • Oregon
    • Pennsylvania
    • Puerto Rico
    • Rhode Island
    • South Carolina
    • South Dakota
    • Tennessee
    • Texas
    • Utah
    • Vermont
    • Virgin Islands
    • Virginia
    • Washington
    • West Virginia
    • Wisconsin
    • Wyoming
    Please Select
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curacao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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  • 7
    • Male
    • Female
    • Other
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  • 8
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    Enter
  • 9
    Use your camera to scan the bar code on the vial. "Results" with the number will be displayed when scan is successful.
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    Enter
  • 10
    Found on the testing vial. This will link your saliva sample to your account.
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  • 11
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    Enter
  • 12
    Please check all that apply. (Government Reporting Requirement.)
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  • 13
    (Government Reporting Requirement.)
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  • 14
    Your test results will be securely emailed to this address when available.
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  • 15
    In case of a positive test result, this will be the phone number TouchCare uses to contact you.
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  • 16
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  • 17
    1 of 4
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  • 18
    Pick a Date
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  • 19
    The current time is pre-populated. Adjust the time if you are testing at a different time.
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    • 59
    AM
    • AM
    • PM
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  • 20
    • Eastern Time (Washington, DC)
    • Central Time (Chicago)
    • Mountain Time (Denver)
    • Pacific Time (Los Angeles)
    • Alaska Time (Anchorage)
    • Hawaii-Aleutian Time (Honolulu)
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  • 21
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  • 22

    I acknowledge that the information I've given is accurate and complete.     

    1.         By signing my name below, I authorize ­­­P23 Labs, LLC (“Laboratory”) to use and disclose the following information related to my care: my first and last name, date of birth, and the results of my laboratory testing conducted by Laboratory, including test results for the presence of SARS-CoV-2, the virus causing COVID-19.

    2.         I authorize any employee or agent of the Laboratory to disclose the above-described information to TouchCare LLC (“TouchCare”).

    3.         The purpose of this disclosure is to allow TouchCare to quickly provide me with my test results for the presence of (Covid-19) and provide me with any relevant information concerning my test results.

    4.         This laboratory test has been approved by the United States Food and Drug Administration (“FDA”), however, I understand that this test alone may not be sufficient to detect or rule out the possibility that I have been exposed to or are infected with COVID-19. I should carefully monitor my own symptoms, and, notwithstanding the results of any testing, I must stay home and consult with my physician if I experience symptoms of COVID-19.

    5.         In order to collect samples for laboratory testing, the Laboratory utilizes an FDA EUA Oral Fluid Collection device approved for self-collection, which can be completely self-collected in most cases. FDA EUA Covid-19 Diagnostic Test which facilitates the detection of nucleic acid from SARS-CoV-2 in order to determine the presence of Covid-19 in the sample, which indicates whether I have tested positive or negative for Covid-19.

    6.         I understand that if I do not sign this authorization, I will not receive laboratory testing or related services from Laboratory at this time.

     7.         This authorization will be effective for one (1) year from the date signed below.  I have the right to revoke this authorization at any time by notifying Laboratory My revocation of this authorization must be in writing. My revocation will not be effective to the extent Laboratory has already relied upon this authorization (by disclosing information to TouchCare).

    8.         The information disclosed as a result of this authorization may be subject to redisclosure by the recipient and no longer be protected by the federal HIPAA privacy rules.

    9.         I have the right to discuss the proposed testing with my physician, to learn about the purpose, potential risks and benefits of any testing. Because of the ongoing public-health crisis, it may be necessary for The Laboratory and TouchCare to share the results of my test with public health authorities. By signing below, my consent to the disclosure of such information as requested, recommended or required by federal, state, and local public health authorities.

    10.       I have read and understood the content of this Authorization to Use and Disclose PHI. This authorization correctly describes my request of the Laboratory. I understand that by signing this form, I am voluntarily giving my permission for the Laboratory to use and/or disclose my PHI to TouchCare. I understand that I have the right to revoke this authorization at any time by providing a signed, written notice of such revocation to the Laboratory, except to the extent the authorization has already been relied upon. I understand that the information released pursuant to this authorization may no longer be protected by law or regulation and may be redisclosed by the recipient.

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  • 23

    Acknowledgment of Non-Doctor-Patient Relationship

    I understand that I am not entering into a doctor-patient relationship with TouchCare LLC, P23 Labs LLC, or the Ordering Medical Provider, and that any questions or required follow up shall be my responsibility to arrange with my own physician.

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  • 24
    Clear
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  • 25
    Relationship to Individual and Authority of Personal Representative (e.g., parent, health care power of attorney, guardian, other statutory authorization)
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