COVID TEST DR. REVIVE

20315 Ventura Boulevard Suite #315 A, Woodland Hills, CA 91364
SARS-COV-2 (COVID-19, QUALITATIVE, NCA) CONSENT FORM
Patient Information--**Must provide Driver’s License or type of ID**

This test is for diagnostic purposes ONLY. Please double-check with your airline if they accept an antigen test. This test is non-refundable.
FULL NAME *

First Name Last Name
Address *

Physical/Street Address (P.O. Box is NOT accepted)

Street Address Line 2

City State

Zip
Phone: *
Email: *
Gender *

Male Female
Date of Birth: *

Month Day Year
Date
If the patient is under 18 years, name of parent/ legal guardian:
(Parent/Guardian First Name & Last Name)

First Name Last Name
Reason for COVID-19 Testing (please check all that apply) *

I have symptoms of COVID-19 (if yes, please check off all symptoms you have experienced) My work is requiring me to get tested I have had contact with someone who has COVID-19 Traveling (Please double check with your airline) Fever Shortness of Breath Diarrhea Headache Red Eyes Sore Throat Chills Muscle aches Runny Nose Vomiting Cough Abdominal Pain Nausea Other:
First Covid Test? *

Yes No
Are you Symptomatic? *

Yes No
Note: For Symptomatic Patients

with Fever, chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea.
Have you been Hospitalized? *

Yes No
Were you in the ICU? *

Yes No
Are you employed in Health Care? *

Yes No
Note: First responders

front line clinicians, nursing home staff, environmental staff, or therapists in direct contact with patients.
Are you living in a congregate setting? *

Yes No
Note: Nursing home

residential care location for people with intellectual and developmental disabilities, psychiatric treatment facility, group home, dormitory, board and care home, homeless shelter, foster care or other setting.
Are you pregnant? *

Yes No
How did hear about us?

Google Yelp Instagram Facebook Youtube Other:
Others please explain:
Please carefully read and sign the following Informed Consent:

a. I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab or blood draw, as ordered by an authorized medical provider or public health official.

b. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.

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

d. I understand the testing unit 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.

e. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.

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 *

Clear
Take Photo: Driver’s License or Photo ID. (PLEASE MAKE SURE THE PICTURE IS STRAIGHT) *

Payment: Select ONE option only

CREDIT CARD: Antigen Rapid Test (Nose swab) Rapid Detection of SARS-CoV-2 nucleocapsid antigens in nasal swabs from individuals who are suspected of COVID-19 Results in 15 min

$ 199.00

CREDIT CARD: Antibody Test for COVID-19 Antibody Test For Covid-19🦠 Get the results in less than 10 minutes.

$ 75.00

CASH: Antigen / Antibody Rapid Test Please select this if paying with Cash $75-$199

Free

Total

$ 0.00

Credit Card:
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Appointment (SKIP IF WALK-IN)
Should be Empty:

20315 Ventura Boulevard Suite #315 A, Woodland Hills, CA 91364

SARS-COV-2 (COVID-19, QUALITATIVE, NCA) CONSENT FORM

Note: For Symptomatic Patients

Note: First responders

Note: Nursing home