Please read the consent below.
I am at least eighteen (18) years of age. I voluntarily consent and authorize InnerHealth Laboratory and their school partners, any of their respective officers, directors, employees, representatives, and agents to conduct the collection, testing, and analysis for the purposes of a viral diagnostic test for myself and/or my child(ren) and/or my legal dependent(s) as applicable.
I understand that the type of test I am signing up for is a COVID-19, Influenza, and/or RSV molecular reverse-transcriptase polymerase chain reaction [PCR] test to detect the presence of viral genetic material. These test will consist of a self-collected nasal swab, or in some cases other FDA-authorized collection processes.
To the fullest extent permitted by law, I hereby release, discharge, and hold harmless, InnerHealth Laboratory, without limitation, any of their respective partners, officers, directors, employees, representatives, and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19, Influenza, and/or RSV diagnostic test or the disclosure of my COVID-19, Influenza, and/or RSV test results to my Employers and other Government Agencies.
I understand and agree that my COVID-19, Influenza, and/or RSV test results may be sent to me by telephone or email by InnerHealth Laboratory.
I hereby authorize and direct InnerHealth Laboratory, Inc to release my COVID-19, Influenza, and/or RSV test results, to the following Designated Recipient:
Irvine Unified School District Administration (“Designated Recipient”)
The Designated Recipient has requested that Healthcare Provider test certain employees for COVID-19, Influenza and/or RSV; the Test results will be used by Designated Recipient for the purpose of mitigating the spread of COVID-19.
I authorize the disclosure of my COVID-19, Influenza, and/or RSV test results to such organization.
1) RT-PCR/Antigen nasal swab test (COVID-19, INFLUENZA, and/or RSV) – a sample taken from the oral/nasal passages - which usually takes a few days to get the lab results. A positive result indicates the presence of a current Covid-19 viral infection.
2) PCR saliva test (COVID-19 ONLY) - a sample of saliva collected in a vial. A positive Covid-19 result indicates the presence of a current Covid-19 viral infection.
Any positive results from either test would need to be followed up with further tests by your doctors. A negative test result is not a 100% guarantee that you do not have the Covid-19, Influenza, and/or RSV infection and does not guarantee that you will not get it in the future either.
I am also fully aware that InnerHealth Laboratory is not providing any medical care or giving a medical diagnosis with testing and that I should consult my healthcare provider or go to an emergency room if I have any serious symptoms and/or to obtain medical advice from my own doctor as to the results of the testing.
The information provided above is true to the best of my knowledge. If my employer does not cover the cost of the test, I authorize InnerHealth Laboratory to bill my insurance, or if no insurance and I cannot afford to pay, InnerHealth Laboratory will waive testing fees under 'financial hardship' for the services provided to me.