Please carefully read before agreeing to the following.
I. Informed Consent: (a) I authorize JFI Medical LLC, T. Leroy Jefferson Medical Society, Centerpoint Medical, Teledactyl & Premiere Healthcare for Women and any agent or referral laboratory to conduct collection and testing for COVID-19 through a nasopharyngeal swab or oral rinse; (b) I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law; (c) I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others; (d) I understand that JFI Medical LLC, T. Leroy Jefferson Medical Society, Centerpoint Medical, Teledactyl & Premiere Healthcare for Women is not acting as my medical provider, this testing 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 I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens; (e) I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.
II. Release Of All Claims: (a) to the fullest extent permitted by law, I hereby release, discharge and hold harmless JFI Medical LLC, T. Leroy Jefferson Medical Society, Centerpoint Medical, Teledactyl & Premiere Healthcare for Women including, without limitation, its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, known or unknown, including negligence, 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; (b) I hereby discharge JFI Medical LLC, T. Leroy Jefferson Medical Society, Centerpoint Medical, Teledactyl & Premiere Healthcare for Women, its agents and employees from any and all liabilities, responsibilities, damages and claims which might arise from the release of my health information authorized herein, compiled during my visit, encounter or testing, or making copies thereof in accordance with policies of this facility.
I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have had the opportunity to print or receive a copy of this Informed Consent and Release Of All Claims; (i) I am over the age of 18 and the individual or legal guardian of the individual identified above, I have been given the opportunity to ask questions before I sign, I understand that I can ask additional questions at any time, and I voluntarily agree to this testing for COVID-19.