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

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

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

  • Patient Information--**Driver’s License or Government issued 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. 

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  • If the patient is under 18 years, name of parent/ legal guardian:
  • 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.
  • 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.

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