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Client COVID-19 Testing Intake Form

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  • COVID-19 TESTING CONSENT FORM I give permission for LAB to YOU LLC staff to perform a COVID-19 test on me. The testing process has been explained to me, and I have had an opportunity to ask any questions I may have. I understand that while this test has been approved by the FDA, under the EUA (Emergency Use Authorization), this test alone may not be sufficient to detect or rule out the possibility that you have been exposed to or are infected with COVID-19. I acknowledge that LAB to YOU LLC cannot guarantee the accuracy of the result and that it may be necessary for me to undergo additional testing in the future. I recognize that even if I have a negative result now, I can still contract COVID-19 in the future. Administering the test does not create a patient/physician relationship between me and LAB to YOU LLC or any of its employees, nor does it obligate LAB to YOU LLC or its staff to perform any other care or treatment for me. I authorize LAB to YOU LLC to receive my test results and convey them to me. I understand by undergoing the test LAB to YOU LLC may have to report the results to the Department of Health or other agencies. I HERBY CERTIFY THAT I HAVE READ THE ABOVE ACKNOWLEDGEMENT AND HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENTS. BY SIGNING BELOW, I CONSENT TO UNDERGO THE COLLECTION AND LABORATORY TESTING UNDER THE CONDITIONS SET FORTH HEREIN.
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  • I understand that as part of my testing, LAB to YOU originates health records describing my test result. By clicking 'accept' I agree to the terms of the HIPAA Privacy Rule of Patient Authorization Agreement. I also give my permission for LAB to YOU to release my test results to other healthcare providers, my employer, and local, state and federal agencies.
  • Please carefully read and indicate acceptance of the following Informed Consent: I (or legal guardian for minors) authorize this COVID-19 testing unit to conduct collection and testing for COVID-19. I authorize my test results to be disclosed to the county, state, or to any other government entity as may be required by law. 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 by applicable government mandates and guidelines in an effort to avoid infecting others. 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 that I will seek medical advice, care and treatment from my medical provider if I have questions or concerns about this test or the results therefrom, or if my condition worsens. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. Release: To the fullest extent permitted by law, I hereby release, discharge and hold harmless, LAB to YOU LLC, including, without limitation, any of its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results. 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 click Accept, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19. I specifically assume the risk of testing and agree to release and waive any claim arising from my selection to receive this voluntary screening. I fully indemnify LAB to YOU for any, and all costs it may incur as a result of any claims with respect to my testing.
  • Certain infectious diseases, conditions, and the identity of those who test positive for them, are required by federal, state or local regulations has to be reported to local or state health authorities by LAB to YOU LLC. The time frames and reporting requirements vary according to the disease or condition. Accordingly, I understand that if I test positive for any infectious disease or condition on the states list of reportable conditions, including but not limited to COVID-19, my test results and my identifying information will be reported to the applicable local, state and/or federal health authority. Additionally, I understand that if I test positive for any infectious disease or condition, neither LAB to YOU LLC, their staff, or the third-party testers that run the tests, will diagnose, treat, prescribe medications, or refer me for medical treatment. It is my sole responsibility to seek and comply with necessary treatment and all required follow-up with my healthcare provider.
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  • Consent Form