COVID-19 Rapid Testing Consent and Release Form LTC Scheduler

Full Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Date of Birth*

County*

Biological Sex*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Race: Please check the box(es) next to the one(s) that best describes your race.*

Hispanic or Latino: Please check the box next to one of the following that best describes your ethnicity:*

Latino or HispanicNot Latino or HispanicUnknown or Decline to Specify

Do you have symptoms as defined by the CDC?

Circle/Check all that apply

Is this your first COVID test?

Are you employed in healthcare?

Are you a resident in a congregate setting? (i.e. carehome, long term care facility)

Are you pregnant?

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Please carefully read and sign the following Informed Consent and Release:

I authorize 5 Minute Pharmacy to conduct collection and testing for COVID-19 through a nasopharyngeal swab, oral swab, or other recommended collection procedures.

I understand and consent that 5 Minute Pharmacy may use my personal information in communicating with other healthcare providers and labs. 5 Minute Pharmacy may send my sample for laboratory analysis.
I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law. If this is an employer-sponsored test, I authorize my test results to be disclosed to the employer or any other party sponsoring my testing.

I acknowledge that a positive test result is an indication that I must self-isolate and wear a mask or face covering as directed in an effort to avoid infecting others.

I understand 5 Minute Pharmacy is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.
I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result; I will not hold 5 Minute Pharmacy liable for such errors.

To the fullest extent permitted by law, I hereby release, discharge, and hold harmless, 5 Minute Pharmacy, including, without limitation, 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 diagnostic test or the disclosure of my COVID-19 test results.

I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.

Signature*

Date*

Date

Guardian Signature - If signing here, place a line through the above "Signature" field.

Date

If signing on behalf of the patient, please give the reason why the patient can't consent for themselves (e.g. patient is under 18 or has cognitive or intellectual impairment):

COVID-19 Testing Consent and Release Form