If you have ANY of the following symptoms:

CALL 911 OR SEEK EMERGENCY MEDICAL CARE AT THE NEAREST HOSPITAL

• Difficulty breathing
• Persistent pain or pressure in the chest
• New onset confusion
• Inability to wake or stay awake
• Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone

I authorize a Rapid Antigen COVID‐19 Test as ordered by the authorized healthcare provider. I further understand, agree, certify, and authorize the following:

The person named above is consenting to the Rapid COVID‐19 testing.

This test has been authorized by FDA under an Emergency Use Authorization (EUA).

I understand that this test does NOT rule out COVID‐19 in ALL COVID‐19 Patients. The possibility of a false negative result should be considered in the context of recent exposures and the presence of clinical signs and symptoms consistent with COVID‐19. If COVID‐19 is still suspected based on exposure history together with other clinical findings, re‐testing or testing with molecular methods should be considered.

I understand this test is for COVID‐19 screening purposes ONLY. This screening event is NOT for medical or life‐threatening medical emergencies. This screening event is NOT intended for diagnosis, treatment, recommendation and/or management of ANY medical conditions. This screening event is NOT a substitute for your regular healthcare provider visit.

By signing below I acknowledge that I have read, understand, agree, certify, and/or authorize the information above and further agree to hold harmless, Advanced Practice Clinic, its employees, agents, and contractors from any and all liability and claims.