ARCpoint Labs of Tampa COVID19 ANYIBODY Pre-Test Consent Form

Pre-Test Consent Form
COVID-19 Antibody Testing
Patient Name:
Today's Date
MonthDayYear
Date
Date of Birth:
MonthDayYear
Date
Phone
E mail:
example@example.com
(Street#/PO BOX)
(City)
(State)
(Zip Code)
When were you symptomatic?
Did You have a positive RNA test?
Allergies
I understand that this test looks for antibodies to COVID-19, NOT the virus itself. Testing for viral DNA, via PCR analysis, is performed only in specifically designated places and on patients who meet a strict pre-test criteria. I am electing to have this antibody test to assess whether or not I have been exposed to the novel coronavirus in the past. I additionally understand that if I choose to have this test fewer than seven days after the resolution of symptoms, the results may be less reliable.
I hereby attest that I have been advised to take this test only as a completely asymptomatic individual. I have never had symptoms or at least have been symptom-free for seven days.
I also understand that the results of this test may be given to the department of health or CDC for their statistical and demographic value. I have been given a copy of the Behavioral Guidelines sheet for my/my employer’s reference.
Once I am given my results for this test, I understand that they are only a preliminary measure of IgG/IgM antibodies (qualitative measure) and that the values of antibodies (quantitative measures) may vary. This test does not guarantee immunity to COVID-19 or any other virus.
Initial here to release results to an employer/organization/other person.
Initial
Clear
Enter Person's email/Company's email to release results to:
Patient Signature
Clear
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COVID-19 ANTIBODY TESTING$82.95
One Test for COVID-19 ANTIBODY TESTING: Insurance CPT Code 86769

Total $0.00
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Pre-Test Consent Form

COVID-19 Antibody Testing

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