Please read the consent below.
I am at least eighteen (18) years of age. I voluntarily consent and authorize the the Clinical Lab and their partners, any of their respective officers, directors, employees, representatives, and agents to conduct the collection, testing, and analysis for the purposes of a COVID-19 diagnostic test for myself and/or my child(ren) and/or my legal dependent(s) as applicable.
I understand that the type of test I am signing up for is a COVID-19 molecular reverse-transcriptase polymerase chain reaction [PCR] test to detect the presence of viral RNA. The test will consist of a self-collected nasal swab, or in some cases other FDA-authorized collection processes.
To the fullest extent permitted by law, I hereby release, discharge, and hold harmless, the the Clinical Lab, without limitation, any of their respective partners, 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 to my Employers and other Government Agencies.
I understand and agree that my COVID-19 test results may be sent to me by text message, telephone, or email by the Clinical Lab or any third-party organization, and I authorize the disclosure of my COVID-19 test results to such organization. I understand and agree that
I have read the contents of this form in its entirely and voluntarily consent to undergo diagnostic for COVID-19 testing and release of the result to my employer and other government health agencies. And I agree that the Lab can send the test result notification to my mobile phone via short message (Text message). Consent and registry for covid-19 PCR test or Anti-body test by a Primary Care Physician (clinic).
1) PCR nasal swab test – a sample taken from the oral/nasal passages - which usually takes a few days to get the lab results. A positive result
indicates the presence of a current Covid-19 viral infection.
2) Anti-body Tests (finger pricking): Antibody tests are usually a finger-prick blood test, which can provide results in 10 to 15 minutes. A positive result would indicate you have had a recent Covid-19 infection (several days to several months ago).
Any positive results from either test would need to be followed up with further tests by your doctors. A negative from 1) and 2) are not a
100% guarantee that you do not have the Covid-19 infection and does not guarantee that you will not get it in the future either.
I understand that Clinic may make telehealth and/or in-person visits, or on-site interviews with me to discuss the related test(s) and relevant
health conditions, how to manage a positive test, and upcoming vaccination. if needed, and typically provides a follow-up
call(telemedicine) with the individual results of the test each time within a few days to address any question(s). Repeated test may be needed as clinically indicated
The information provided above is true to the best of my knowledge. If I am not self-paid for the services, I authorize Pacific Horizon
Medical Center to bill my insurance or if no insurance, and cannot afford to pay, Clinic will bill Covid-19 government program for the
services provided to me (including testing and office visit and/or telemedicine).