COVID-19 Testing Consent Form

Please complete the following information
Free PCR TEST will need insurance proof .

Uninsured Patients PCR test will cost - 100 USD
First name *
Last name *
Date of birth *

Month Day Year
Date
Email (Results will be sent on this Email) *
Required to receive Results
Gender *

Male Female Other
Phone Number *
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Patient COUNTY of residence *
What is your Race/Ethnicity *

White Hispanic Latino African-American Asian American Indian Alaskan Native Native Hawaiian Pacific Islander Other Decline to disclose
Please select Test *

PCR (Free , Results in - 48-72 hours) EXPEDITED RT-PCR (Travel Recommended or Quick Results-$150,Results in 24 hours ) PCR (Uninsured Patients - $100 Results in 48-72 hours)
Starting March 18 2022 ,Uninsured Patients PCR Test prices have incresed to $100.
What Date and time you need your Results ?

Month Day Year

Hour Minutes AM/PM Option
Do You have a valid Health Insurance ? *

YES, I have a valid health insurance NO, I do not have health insurance
Insurance Name *
Insurance ID *
Upload Insurance Front and Back *

Cancel of
Drivers License No OR State Id OR Passport Number *
Upload Drivers License OR State Id OR Passport (OPTIONAL)

Cancel of
1.Have you traveled anywhere outside of California in the past 1 month? *

YES NO
2.Have you been in close contact (i.e. within 6 feet) with someone confirmed to have COVID-19? *

YES UNKNOWN
TESTING ELIGIBILITY
COVID-19 diagnostic testing, authorized by the Food and Drug Administration under an Emergency Use Authorization (EUA), will be used .
6. Please mark any symptoms you are currently experiencing *

Fever Muscle aches Headache Cough Nausea and vomiting Shortness of breath Diarrhea Tiredness, Fatigue Sore throat Other or Exposed
INFORMED CONSENT FOR CORONAVIRUS (COVID-19) TESTING
7 . Please Read this carefully

a. I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab, as ordered by an authorized medical provider or public health official.

b. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.

c. I acknowledge that a positive test result is an indication that I must continue to self-isolate in an effort to avoid infecting others.

d. I understand that I am not creating a patient relationship with BDL Lab by participating in testing. Iunderstand the testing unit is not acting as my medical provider. Testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate action with regards to my test
results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.

e. I understand that, as with any medical test, there is the potential for false positive or false negative test results can occur. BDL lab collection site takes no responsibility of results obtained .

f. In case of minor patients , Parents/Gaurdians provides consent to authorize Covid -19 testing to BDL lab .

F . The undersigned, voluntarily agree to testing for COVID-19.
Signature of patient/guardian *

Clear
Date *

Month Day Year
Date
Relationship to patient ( If minor)
Should be Empty:

Starting March 18 2022 ,Uninsured Patients PCR Test prices have incresed to $100.

TESTING ELIGIBILITY

INFORMED CONSENT FOR CORONAVIRUS (COVID-19) TESTING