Flu & Strep Test Consent Form

Testing Consent Form
Appointment*
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Date Today

MonthDayYear
Date
Gender
Name of your Primary Care Provider (PCP)

First NameLast Name
PCP Phone Number
Please enter a valid phone number.
Medication Allergies and Reaction:*
Current Medications (Rx, OTC, supplements, etc.)*
Treatments Tried for Current Condition (if none, indicate N/A)*
Name of Test*

Influenza, 18 years or older - $59Influenza, 6-17 years old - $59Group A Strep, 18 years or older - $39Group A Strep, 6-17 years old - $39Other
Have you ever been diagnosed with a weakened immune system (cancer, HIV/AIDS, transplant, etc.)?*

YesNo
Do you require supplemental oxygen therapy?*

YesNo
Are you a resident of a nursing home or long term care facility, in hospice, or receiving home health services?*

YesNo
Do you have a history of rheumatic fever, rheumatic heart disease, scarlet fever, or acute GAS pharyngitis induced glomerulonephritis?*

YesNo
Have you had a tonsillectomy in the previous 30 days?*

YesNo
Do you have a history of kidney disease or reduced kidney function?*

YesNo
Do you have any of the following symptoms? Check all that apply:*

FeverSore throatPain wwallowingSwollen/tender cervical lymph nodesInflamed or swollen tonsils or uvulaNasal congestionMuscle/body achesCoughOther
Do you have a pending test for your symptoms (COVID, strep, flu)?*

YesNo
Have you tested positive for influenza in the last four weeks?*

YesNo
When did your symptoms start?*

Less than 2 days ago2-4 days agoMore than 4 days ago
Have you received any vaccinations or skin tests in the past 4-8 weeks?*

YesNo
Please list below
I hereby give my consent to the testing as specified in the choice above.

I hereby release and hold harmless the facility, its staff, agents, employees, successors, affiliates, subsidiaries, directors, and officers from any and all liabilities or claims whether known or unknown arising from, or in connection with the testing listed above.

I authorize the disclosure of my information for the purpose of necessary processing, recording of my information relevant to the administering of the test including claims for costs and fees.

I agree to be responsible for any financial cost-sharing amounts, including copays, coinsurance, and other deductibles including those which are not covered by my insurance benefits.
Age of Consent*

I hereby declare that I am at least 18 years old and I give my consent with full knowledge and responsibility to the risks and benefits of the test. I have had the opportunity to ask questions and which answers were given to me to my satisfaction.I am the legal representative of the above-named patient. The patient is of legal age and I am executing this document on his/her behalf. He/she have had the opportunity to ask questions and which the answers were provided to him/her to his/her satisfaction.I am the legal guardian of the above-named patient. I am executing this document on his/her behalf with my full consent and authority. I have had the opportunity to ask questions and by which answers were given to me to my satsifaction.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Testing Consent Form