COVID-19 Testing Form

For your convenience, we are offering rapid COVID-19 antigen testing in our office for asymptomatic individuals to facilitate return to work, return to school and to meet travel or sports participation requirements. Please note, we are not a drive thru facility, therefore, it will be necessary to enter our office suite for testing. If you are sick or have a known exposure to COVID-19, please see your personal physician.

SENDER'S NAME

FIRST NAME*

LAST NAME*

DATE OF BIRTH*

Date

GENDER (AS ASSIGNED AT BIRTH)*

MALEFEMALE

GENDER OUTPUT

ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code

PHONE NUMBER*

Please enter a valid phone number.

EMAIL ADDRESSS

example@example.com

PRIMARY CARE PROVIDER / REFERRING PHYSICIAN'S INFORMATION

PRIMARY CARE PROVIDER OR REFERRING PHYSICIAN'S NAME

PRIMARY CARE PROVIDER OR REFERRING PHYSICIAN'S PHONE NUMBER

Please enter a valid phone number.

PLEASE ATTEST TO THE FOLLOWING BY INITIALING EACH STATEMENT

I have no reason to believe that I have been directly exposed to COVID-19 *

I understand that the coronavirus testing that I am receiving today is being done for asymptomatic people who need it for a purpose other than the individual diagnosis and treatment of COVID-19 and therefore it is not medically necessary *

I agree to pay the $125.00 test fee by cash or credit card*

I understand that today’s service is limited to the rapid COVID-19 test*

This test has not been FDA cleared or approved;
This test has been authorized by FDA under an Emergency Use Authorization for use by authorized labs; This test has been authorized only for the detection of proteins from SARS- CoV-2, not for any other viruses or pathogens; and,
This test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of the virus that causes COVID-19 under Section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner. For information regarding the Sofia SARS Antigen Fluorescent Immunoassay and guidance regarding results please go to https://www.fda.gov/media/137887/download.

I voluntarily consent and authorize Alan Morrison DO LLC to conduct collection and testing for the purposes of a rapid COVID-19 test. I acknowledge and understand that my COVID-19 test will require a nasal swab to obtain a sample. I understand that there are risks and benefits associated with undergoing a test for COVID-19 and there may be a potential for false positive or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have questions or concerns regarding my results, or a worsening of my condition ( which is currently asymptomatic), I shall promptly seek advice and treatment from an appropriate medical provider.

NOTICE OF PRIVACY PRACTICES >>

ACKNOWLEDGMENT*

I acknowledge and agree that I have reviewed and agree to Alan Morrison DO LLC’s Notice of Privacy Practices, which can be viewed at the link above.

I acknowledge and agree that Alan Morrison DO LLC may disclose my test results and associated information to appropriate governmental and regulatory entities as required by law.

To the fullest extent permitted by law, I hereby release, discharge and hold harmless, Alan Morrison, DO, LLC including, without limitation, any of its respective 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 test or the disclosure of my COVID-19 test results.

I acknowledge and agree that I have read, understand, and agree to the statements contained within this form. I have been informed about the purpose of the COVID-19 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 test, I may decline to receive this service. I voluntarily consent to undergo rapid testing for COVID-19.

FULL NAME*

SINGATURE

DATE OF SIGNING*

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

THE TEST BEING PREFORMED IN OUR OFFICE IS THE SOFIA SARS ANTIGEN FLUORESCENT IMMUNOASSAY

INFORMED CONSENT

HIPAA

DISCLOSURE

RELEASE

COVID-19 Testing Pre-Payment