I understand that I am scheduling to receive testing for COVID-19 for myself or a minor on whose behalf I am authorized to provide consent.
I have been informed that testing is voluntary, that I have the right to decline any tests and that positive test results will be reported to the state health department where required by law.
I understand that, as with any medical test, there is the potential for false positive or false negative test results.
I consent to testing for COVID-19 and agree to these terms.I understand that possible discomfort or other complications, such as the potential for a bloody nose, can happen during sample collection.
I acknowledge that I have received a copy of the Notice of Privacy Practices (PDF). I herby give my consent to the pharmacist and pharmacy staff members from Pineville Pharmacy to perform a COVID-19 Rapid Antigen Test and/or PCR test at my own risk and authorize the Pineville Pharmacy and it’s staff member to maintain a copy of this signed form.
On behalf of myself, my heirs, and personal representatives, I indemnify the organizing body and all persons connected with Pineville Pharmacy from all claims that may result from my voluntary participation in the tests.
I also give my consent to submit my or my representatives results to the North Carolina Department of Health or any other healthcare agency, as required by law. By signing below or submitting this form, I signify that I agree to allow those pharmacists affiliated with the pharmacy named above to administer the Covid-19 test for a listed price.