COVID-19 PATIENT TESTING INFORMED CONSENT AND AUTHORIZATION

​

Please carefully read the following informed consent and sign it in the space indicated below if you understand and agree with each of the following statements:

I understand that US Lab requires a signed consent for COVID-19 testing. I understand I need to sign it before my child and/or myself as a patient 18 years of age or older can be tested. I give consent to US Lab and its employees and/or contractors to examine and test my child and/or myself by signing this form. As used here, the terms “I”,  “me” or “myself” include any minor child on whose behalf I am signing this consent.

I authorize US Lab to conduct testing for COVID-19 through the collection and processing of a nasopharyngeal (nose) or an oropharyngeal (throat) swab as ordered by my physician or authorized healthcare provider.  The swab procedure used to obtain the sample may be uncomfortable.

I understand that COVID-19 testing is not 100% reliable, and that, as with any medical test, there is a potential that false positive or false negative test results can occur.  I understand that, even if I receive a negative test result, the test in some cases may fail to detect the virus.

I understand that processing of the specimen and results may take up to 5 days (typical turnaround time is 24-48 hours).

I understand and acknowledge that I am not creating a patient relationship with US Lab, that US Lab cannot provide treatment for COVID-19 or my symptoms, and is not providing me with any medical advice.  Testing does not replace treatment by my medical provider.

I understand that I remain solely responsible for seeking appropriate treatment based on the results of my test, and that my physician or other health care professional may want to conduct additional testing.  I agree that I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition changes or worsens.

I understand that my physician or authorized healthcare provider will be responsible for providing testing results, interpreting test results, explaining testing limitations, and providing any additional diagnostic or clinical services I may require.

I understand that, if my test result is positive, US Lab may be required by law to report that result to certain public health agencies, including the California Department of Public Health and the Centers for Disease Control and Prevention.  Additionally, the information I share may be used and disclosed consistent with the Notice of Privacy Practices I have been provided.

I authorize US Lab to share and release my test results or other necessary information, as applicable, to the school requiring this test, employer requiring this test, the facility where I reside, or my medical provider requiring this test. I understand that my test results will also be shared with the county, state or any other governmental entity as may be required by law. I hereby waive and release US Lab and its shareholders, officers, directors, agents, contractors and employees to the fullest extent permitted by law from any and all liability arising out of or relating to my COVID-19 testing or the release of information regarding my test results.

I agree to be contacted by phone, cell phone, mail, or e-mail by US Lab.  By providing US Lab with my cell phone and/or landline phone, I agree to be contacted via text message, voice and/or recorded call by US Lab or its contracted business associates for all healthcare calls.

By my signature below, I acknowledge and represent that I have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this informed consent. I was given the opportunity to ask questions before signing this document, and I have been informed that I can ask other questions at any time.  I voluntarily agree to undergo testing for COVID-19.

My signature below means that I have given truthful information about the patient’s name and identity. It also means that I understand:
 

• How important it is to provide truthful and accurate information about the patient’s name and identity.

• That incorrect or false information about identity can lead to treatment that could be harmful to the patient