INFORMED CONSENT FOR COVID-19 RAPID TESTING

1. Please complete the following information:

Patient Name

Date of Birth

Date

Age

Address

Patient Address

Street Address Line 2

Zip

County of Residence

Patient Phone Number

Email

example@example.com

Patient Ethnicity

Native Hawaiian/Other Pacific Islander.

WhiteBlack/African AmericanAsian

Hispanic/Latino

American Indian/Alaskan Native

Have you been in contact with anyone who has covid in the last 1-4 weeks?

NO

YES

UNKNOWN

1. Authorization and Consent for Covid-19 Testing:

I give Dr. Adam Persky and Dr Silva Battaglin of TOBP LLC Testing ("TOBP LLC") of, 2685 South Rainbow #107 Las Vegas, NV 81946 to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test. I acknowledge and understand that my COVID-19 testing will require the collection of an appropriate sample by through a single drop of blood, a nasal swab or other recommended collection procedures. I understand that there are risks and benefits associated with undergoing testing for COVID-19 and there may be a potential for false positive and/or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have question or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider.

2. Patient Rights and Privacy Practices

a) Notice of Privacy Practices and Patient Rights: TOBP LLC Notice of Privacy Practices describes how it may use and disclose your protected health information to carry out treatment, initiate and obtain payment, conduct health care operations and for other purposes that are permitted or required by law. I acknowledge that TOBP LLC has provided me with a copy of TOBP LLC Notice of PrivacyPractices

b) Disclosure to Government Authorities: I acknowledge and agree that TOBP LLC may disclose my test results and associated information to appropriate county, state, or other governmental and regulatory entities as may be permitted by law.

3. Release To the fullest extent permitted by law, I hereby release, discharge and hold harmless, TOBP LLC, including, without limitation, any it's respective, doctors, medical professionals, officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results. By signing below, I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I acknowledge that I have a basic command of the English language. I have been informed about the purpose of the COVID-19 diagnostic test, procedures to be performed, potential risks and benefits, and associated costs. I have been provided an opportunity to ask questions before proceeding with a COVID-19 test and I understand that if I do not wish to continue with the collection, testing, or analysis of a COVID-19 diagnostic test, I may decline to receive continued services. I have read the contents of this form in its entirety and voluntarily consent to undergo testing for COVID-19.

Signature of patient/guardian

Date

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