COVID-19 Testing Consent Form

Today's Date

Date

Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

How would you like us to notify you of a negative test? A positive test will always receive a phone call.

Email

example@example.com

Reason for Testing

You selected "Other" for why you want a test. Please explain.

Worried well, work, travel, etc....

I understand my test results will be disclosed to the county and state health entities as requried by law. I acknowledge that a positive test result is an indication that I may by required to isolate to avoid infecting others.

I voluntarily consent to submit to a COVID test and have it analyzed. I also agree to allow the City/County Health Department to disclose my results to my employer if it is deemed necessarily to protect public safety.

Signature