COVID-19 Antibody Screening Consent Form
DISCLAIMER:
Positive test results could indicate antibodies for other coronavirus strains and the test should not be used as a sole basis for diagnosing infection status. The novel coronavirus has many variables and unknowns.
CONSENT:
1. I acknowledge that my participation in this test is completely voluntary and I confirm that there is no mandate or employer-imposed requirement to participate in this antibody screening test.
2. I have read and understood the guide and informational sheet sent by the healthcare organization about the COVID-19 Antibody Screening.
3. My test sample will be given or sent anonymously to a third-party independent laboratory processing and test results may be used for further scientific studies.
4. My personal information will not be shared with anyone else unless there is a positive result of a viral infection.
5. I have been informed that there may be some unforeseen or unpredictable risks during blood drawn and may cause harm, injury, or pain.
I hereby waive all rights and claims; release and discharge this healthcare organization, their past, present and future officials, administrators, professionals, workers, and members for any or all claims and demands including mental, physical and psychological damages, disabilities, and injuries.
Patient Information
Name
First Name Last Name
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Gender
Male Female N/A
Email
example@example.com
Screening Appointment Date & Time
I agree to voluntarily participate in COVID-19 Antibody Screening provided by the healthcare organization which requires blood tests. I have read and understood the consent, guides, and supplemental informational sheets provided by the organization. I have given the opportunity to ask my questions regarding tests and procedures and they were answered completely. I have understood all the risks and benefits and confirm that I release all parties related to this healthcare organization from any and all claims.
Date
Month Day Year
Date
Signature
Clear
Should be Empty:

COVID-19 Antibody Screening Consent Form

Patient Information