COVID-19 Testing Consent Form

COVID-19 Testing Consent Form

Wearing masks and keeping your distance helps prevent the spread of COVID.
Today's Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
How would you like us to notify you of a negative test? A positive test will always receive a phone call.

EmailPhone Call
Email
example@example.com
Reason for Testing

Sick with SymptomsClose Contact (Within 6ft of COVID+ for > 15 mins.)Health Care WorkerFirst ResponderLong-Term Care WorkerSchool Staff/StudentsReferred by Health DepartmentOther
You selected "Other" for why you want a test. Please explain.
Worried well, work, travel, etc....
I understand my test results will be disclosed to the county and state health entities as requried by law. I acknowledge that a positive test result is an indication that I may by required to isolate to avoid infecting others.

I voluntarily consent to submit to a COVID test and have it analyzed. I also agree to allow the City/County Health Department to disclose my results to my employer if it is deemed necessarily to protect public safety.
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