• 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. 

  •  /  /
    Pick a Date
  • 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.
  • Note: First responders

    front line clinicians, nursing home staff, environmental staff, or therapists in direct contact with patients.
  • 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.
  • 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.

  • Clear
  • prev next ( X )
    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:
  • Should be Empty:
Jotform Logo
Now create your own JotForm - It's free! Create your own JotForm