COVID Testing Requisition and Consent Form
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Organization Name *
Appointment Date *
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Patient First Name *
Patient Last Name *
Patient Gender *
Patient Date of Birth (Format: 01/01/2021) *
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Patient Street Address *
Patient City *
Patient State (2 Letter Abbrev) *
Patient Zip Code *
Patient or Guardian Email *
Patient or Guardian Phone Number *
Patient Race *
Insurance Member ID # *
Insurance Group or GRP # *
Insurance Company Name *
I authorize that a test sample be taken for COVID-19 as ordered by authorizing provider (or my child's or legal dependent's physician or authorized healthcare provider). I hereby consent to the release of medical information related to this service for submission of personalized reports to my healthcare providers, insurance carriers and with certain federal, state, or local agencies for public health purposes. I consent to the disclosure of my test results to a designated official of my employer, organization, institution, and/or school. I acknowledge that I have been offered the opportunity to ask questions and discuss with my healthcare provider the benefits, risks and limitations of the test to be performed. I understand that, as with any medical test, the potential for false positive or false negative test results can occur. I agree to assume responsibility for payment of charges for laboratory services that are not covered by my healthcare insurer or by a sponsoring organization. *
I consent to the release of medical information about my child (or myself, if I am the subject of the testing) as relates to COVID-19 testing to the ordering physician and by ordering physician to certain federal, state, or local agencies as required for public health purposes. I also consent to the disclosure of my test results to a designated official of my program or school by either the laboratory or the ordering physician. *
I agree to accept the risk and responsibility for any injury to my child or myself (including, but not limited to, personal injury, sickness, disability, and death), as well as any Illness, damage, loss, claim, liability, or expense of any kind that I or my child may experience or incur in connection with the COVID-19 testing. I hold harmless ordering physician and any employees, agents, and representatives from all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating to the COVID-19 testing, including any claims based on the actions, omissions, or negligence of ordering physician, his/her employees, agents, and representatives. *
E-Signature of Testee or Legal Guardian *
Today's Date *
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By providing my e-signature here and clicking “Submit,” I acknowledge that my submission (a) provides my consent to regular COVID-19 testing as stated and agreed in this Form and (b) has the same force as my signature and that I will abide by the terms and conditions contained in the Covid Testing Requisition and Consent Form. This consent shall remain valid for the period in which COVID-19 is a declared pandemic by the WHO. *
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