COVID-19 Test Request
Please complete the form for COVID-19 testing
Date
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Name *
Date of Birth *
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Social Security Number
Address
City
State
Clear selection
Zip Code
Phone Number
Sex
Clear selection
Race (Check all that apply)
Ethnicity
Clear selection
Do you work in a healthcare facility or congregate setting? (e.g. long-term care facility, shelter, prison, jail)
Clear selection
Do you live in a healthcare facility or congregate setting? (e.g. long-term care facility, shelter, prison, jail)
Clear selection
Is this your first time testing for COVID-19?
Clear selection
Are you symptomatic?
Clear selection
If you answered "Yes" above, when did your symptoms start?
MM
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DD
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YYYY
Are you pregnant?
Clear selection
Insurance provider (if using insurance)
Policy Number
Please carefully read the following informed consent: 1. I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab, as ordered by an authorized medical provider or public health official. 2. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law. 3. I acknowledge that a positive test result is an indication that I must continue to self-isolate in an effort to avoid infecting others. 4. I understand that I am not creating a patient relationship with Aspirar Medical Lab by participating in testing. I understand the testing unit is not acting as my medical provider. Testing does not replace treatment by my medical provider. 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. 5. I understand that, as with any medical test, there is the potential for false positive or false negative test results can occur. ENTER INITIALS TO ACKNOWLEDGE
1. I understand that I may be infected with the virus causing COVID-19 and that I meet criteria for isolation. 2. I agree that while I wait for my COVID-19 test results, I will remain in self-isolation.3 . I agree that if my COVID-19 test results are positive, I will remain isolated for 7 days from this day of testing OR until at least 72 hoursafter my symptoms have resolved, whichever is longer. 4. I agree that if my COVID-19 test results are negative, I will remain isolated until at least 72 hours after my symptoms have resolved.5. I understand that if I am not isolated while ill, I could pose a substantial threat to the health of other persons.6. I agree that I will not come into contact with any other person who is not isolated or ill due to potential COVID- 19 infection. ENTER INITIALS TO ACKNOWLEDGE
I 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 other questions at any time. I voluntarily agree to testing for COVID-19. ENTER INITIALS TO ACKNOWLEDGE
FOR UNINSURED PATIENTS ONLY I do not have health care coverage such as individual, employer-sponsored, Medicare or Medicaid coverage. Therefore, I affirm and attest the above patient qualifies as uninsured according to the COVID-19 Uninsured Program in the Coronavirus Aid, Relief, and Economic Security (CARES) Act (P.L. 116-136). ENTER INITIALS TO ACKNOWLEDGE
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