Binax Now Consent Form

TO BE COMPLETED BY THE ADULT BEING TESTED OR
THE PARENT/GUARDIAN OF THE MINOR STUDENT (LESS THAN 18 YEARS OLD) BEING TESTED
Please provide contact information for the Arizona Department of Health Services and Pima County Health Department to reach you in the event of a positive test result.
This contact information is for*

An adult being testedThe parent/guardian of student being tested
Print Guardian/Adult Name*
Address*
City*
State*
Zip code*
Phone number*
Email address*
example@example.com
Best way to contact you*

Phone callEmail
Demographic Information about the Person Being Tested Demographic information is needed to comply with Arizona Department of Health Services and Pima County Health Department reporting requirements.
Print Tested Person Name*
Date of Birth
MM/DD/YYYY
Gender*

MaleFemaleA different gender not listed above
Race*

American Indian or Alaskan NativeAsianBlack, or African American, or Black AfricanWhiteNative Hawaiian or Other Pacific IslanderA different race not listed above
Ethnicity*

HispanicNon-Hispanic
Employed in healthcare?*

YesNo
Resident in a congregate setting (e.g., care or group home, shelter)?*

YesNo
I consent to the administration of the Abbott BinaxNOW COVID-19 Antigen Card by The Edge School, Inc. for myself or the student named above. I certify each of the following:

(Initial each line separately and sign and date at the bottom. Every line must be initialed for consent to be valid)
I have signed this form freely and voluntarily, and I am legally authorized to make decisions for myself or my student named above.*
Initial
I authorize trained staff using the Abbott BinaxNOW Antigen Card to test the student named above for COVID 19 infection.*
Initial
I understand that there is the potential for false positive and false negative test results. I have been informed that a negative test result will not rule out infection and I am still required to follow The Edge School, Inc. to prevent the spread of COVID 19.*
Initial
I agree that I will follow the public health recommendations regarding the or my student's isolation or quarantine following testing.*
Initial
I understand that The Edge School, Inc. is not acting as my or my student's medical provider and does not replace treatment by my or my student's medical provider. I agree I will seek medical advice, care, and treatment from my medical provider if I have questions or concerns or if my or my student's condition worsens.*
Initial
I understand that all test results and required personal information will be disclosed as permitted by law to the Arizona Department of Health Services, the Pima County Health Department, their contracted services providers.*
I acknowledge that I have received information about the Abbott BinaxNOW Antigen Card and/or can obtain a Fact Sheet about the test at https://www.fda.gov/media/141569/download.*
I understand that this consent form will be valid until 06/30/2022 unless I revoke my consent. I can revoke my consent by contacting The Edge School, signing a statement that I choose to revoke my consent.*
WAIVER OF LIABILITY AND RELEASE OF CLAIMS
Signature of Adult or Parent/Guardian of Minor Student

Clear
Printed Name of Adult or Parent/Guardian of Minor Student*
MM / DD / YYYY*
Today's Date
Should be Empty:

THE PARENT/GUARDIAN OF THE MINOR STUDENT (LESS THAN 18 YEARS OLD) BEING TESTED