Covid-19 $60 Rapid Antigen Testing Consent Form

$60 test available for all eligible patients.

STARTING 2/28/2022 THIS TEST WILL BE ACCEPTED TO CROSS THE CANADIAN BORDER IF DONE WITHIN 24 HOURS OF TRAVEL.

PLEASE SHOW UP AT YOUR SCHEDULED APPOINTMENT TIME. DUE TO HIGH DEMAND OF TESTING AND STAFFING REQUIREMENTS, WE ARE UNABLE TO ACCOMODATE EARLY OR LATE ARRIVALS.

ALL testing must be scheduled online. Please do NOT walk into the store. Please come check in at our drive thru window when your arrive, and we will instruct you on how to proceed to the testing area. All Covid 19 testing will be performed outside.

Rapid COVID-19 Antigen Test

This rapid antigen test is a nasal swab test to see if a person has a current COVID-19 infection. This type of test may be particularly useful if a person has exposure to someone who is suspected to be covid-19 positive. Results from the rapid test will be available same day. You will receive test results via text or email from SimpleReport by the end of the business day. Testing is available by appointment only. Testing is available times posted on the booking page. Individuals should remain in the vehicle at the drive through window. It is important that individuals who are symptomatic or who are close contacts of a positive case continue to quarantine until you receive test results. Please note if you have previously been told to quarantine for 14 days because you are close contact, you will need to continue that entire quarantine period, even if you test results are negative.

$60 Rapid Covid-19 Antigen Test Appointments available *

Name of person being tested *

First Name Middle Name Last Name

Test Recipient Physical Address *

Street Address

Apt #

City State Initials

Zip Code

Sex at Birth *

Date of Birth *

Test Recipient Phone Number *

Email

example@example.com

Parent/Guardian Name (Only for Minors)

Race *

Ethnicity *

DATE OF SYMPTOM ONSET

Date

PLEASE CHECK ALL THAT APPLY *

	Yes	No
Have you had direct contact with someone who is confirmed to have Covid-19?
Have you been tested for Covid-19 in the last 30 days?
FEVER GREATER THAN 100.4
FEELING FEVERISH
CHILLS
COUGH
SHORTNESS OF BREATH
DIFFICULTY BREATHING
FATIGUE
MUSCLE/BODY ACHES
HEADACHE
LOSS OF TASTE
LOSS OF SMELL
SORE THROAT
NASAL CONGESTION
RUNNY NOSE
NAUSEA
VOMITING
DIARRHEA
ARE YOU PREGNANT OR POSSIBLY PREGNANT?
ARE YOU TESTING FOR EVENT ATTENDANCE OR TRAVEL?

Please carefully read the following informed consent notice and sign the authorization to test for COVID-19.

1. I understand that COVID-19 testing of the above-named person (or self) will be conducted through an BD Veritor OR Indicaid antigen test.

2. I understand that the ability of the above-named person to receive testing is limited to the availability of test supplies.

3. I understand the entity performing the test is not acting as the above-named person’s medical provider. Testing does not replace treatment by a medical provider. I assume complete and full responsibility to take appropriate action with regards to the test results, including seeking medical advice, care, and treatment from a medical provider or other health care entity if I have questions or concerns, if the above-named person develops symptoms of COVID-19, or if the above-named person’s condition worsens.

4. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.

5. I understand it is my responsibility to inform the above-named person’s health care provider of a positive test result, and that a copy will not be sent to the above-named person’s health care provider for me.

6. I understand that the antigen test result will be available in 15-30 minutes.

7. I understand and acknowledge that a positive antigen test result is an indication that the above-named person needs to self-isolate to avoid infecting others.

8. I have been informed of the test purpose, procedures, and potential risks and benefits. I will have the opportunity to ask questions before proceeding with a COVID-19 test. I understand that if I do not wish for the above-named person to continue with the COVID-19 diagnostic test, I may decline the test.

9. I understand that to ensure public health and safety and to control the spread of COVID-19, the test results may be shared without my individual authorization.

10. I understand that the test results will be disclosed to the appropriate public health authorities and as otherwise permitted or required by law.

11. I understand that I may withdraw my consent to the testing at any time before it is performed.

I consent to authorize the above-named person (or self) to undergo COVID-19 testing *

Authorization/Consent to test for COVID-19 Clear

Date Signed

Date

My Products *

RAPID ANTIGEN TEST FOR TRAVEL MUST CANCEL AT LEAST 24 HOURS PRIOR TO APPOINTMENT FOR FULL REFUND. CANCELLATIONS WITH 2-23 HOURS NOTICE WILL BE REFUNDED $50.00. IF YOU CANCEL WITH LESS THAN 2 HOURS NOTICE, OR DO NOT CANCEL AND ARE A NO SHOW, YOU WILL NOT RECEIVE A REFUND.

$ 60.00

Total

$ 0.00

Credit Card

$60 Covid-19 Rapid Antigen Testing

Credit Card