COVID-19 Rapid PCR test consent form

PCR Rapid COVID-19 Test COST: $180.00

208 E Main Street Everson, WA 98247 (360)966-3481
THIS IS A PCR TEST - SAME DAY RESULTS

No walk in appointments. ALL testing must be scheduled online. Please do NOT walk into the store if you suspect you may have Covid-19. All testing is done outdoors.

Rapid COVID-19 PCR Test

This rapid PCR 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. Testing is available by appointment only. Individuals should remain in the vehicle and a healthcare professional in personal protective equipment will come to your vehicle to collect the sample. 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. If your test is positive, you will receive a call from public health with further instructions. 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.

Cost of test is $180.00. We are unable to bill insurance.
COVID-19 rapid PCR 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 *

Month Day Year
Test Recipient Phone Number *
Email
example@example.com
Parent/Guardian Name (Only for Minors)
Race *
Ethnicity *
DATE OF SYMPTOM ONSET

Month Day Year
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 Accula RT-PCR test for a cost of $180.00 and insurance can not be billed by Valley Drug.

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 PCR test result will be available in 30 minutes.

7.       I understand and acknowledge that a positive 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

Month Day Year
Date

My Products *

COVID 19 PCR TEST MUST PAY IN FULL FOR TEST AT TIME OF SCHEDULING. MUST CALL AND CANCEL AT LEAST 24 HOURS IN ADVANCE FOR A FULL REFUND. APPOINTMENTS CANCELLED WITH 2-24 HOURS NOTICE WILL RECEIVE A REFUND OF $160.00. REFUNDS WILL NOT BE ISSUED FOR NO SHOW APPOINTMENTS.

$ 180.00

Total

$ 0.00

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PCR Rapid COVID-19 Test COST: $180.00

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