CMD SASS Consent Form

Consent to Test

Safer at School Screening (SASS)
Through the New Hampshire DHHS initiative SASS, you or your dependent may be eligible for COVID-19 screening through an associated school or other qualified organization that has opted into the state program. This consent form must be submitted in order to authorize you or your dependent to be tested by ConvenientMD under this program. By completing and signing this form, it is acknowledged that:
1. If the participant whom may be tested under this program is under the age of 18, a parent or legal guardian consent must be given for the participant.
2. This program is voluntary and you or your dependent are not required to take part in the screenings.
3. The associated school or organization will determine need and time of testing for you or your dependent through the program guidelines.
4. Qualified testing performed under this program will occur at no charge to you or your dependent.
5. By completing this consent form, you are authorizing ConvenientMD to administer and process a COVID-19 test (PCR or Rapid) for you or your dependent, under the SASS program.
6. While rare, it is possible for a sample to be a false positive or negative. Samples may also come back as inconclusive for various reasons.
7. Positive tests results are required be shared with the NH DHHS, Division of Public Health.
8. You will be able to view your, or your dependent's test results within 24 hours after completion of lab processing of sample.
9. This consent authorization will remain in effect for one year from the date of the signature below. You or your personal representative may revoke this authorization at any time by providing written notice. However, your revocation will not apply to any previously released information.
10. ConvenientMD is not liable for the occurrence of a inconclusive, false positive, false negative test, or any resulting actions on part of you or your dependent's associated school/organization.
For more information on the SASS program and related guidelines, please reference the linked program manifest at the end of this form.
Participant Name *

First Name Last Name
Participant DOB *

Month Day Year
Is Participant age 18+? *

Yes No
Participant Gender *
Participant Race *
Participant Ethnicity *
Participant Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Participant Mobile Phone Number *
Please enter a valid mobile phone number.
Participant Email *
example@example.com
Participant School *
Relationship to School *
Guardian Name *

First Name Last Name
Guardian DOB *

Month Day Year
Guardian Relationship to Participant *
Guardian Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Guardian Mobile Phone Number *
Please enter a valid phone number.
Guardian Email *
example@example.com
Participant or Guardian Name *
Must be guardian name if participant is under 18 years
Participant or Guardian Signature

Must be signed by guardian if participant is under 18 years Clear
If unable to sign, type initials here as acknowledgment that typed name above will act as digital signature for this consent
Date Signed *

Month Day Year
Should be Empty:

Consent to Test