Please complete one form for each patient that COVID-19 testing is requested for.

  • Clinical Information

  • Consent

    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 MOHW as may be required by law.
    3. I acknowledge that a positive test result is an indication that I must self-isolate in an effort to avoid affecting others.
    4. I understand that, as with any medical test, there is the potential for false positive or false negative test results.
    5. I understand that testing does not replace treatment by my medical provider nor is the testing unit acting as my medical provider. I assume complete and full responsibility to take appropriate action with regards to my test results.
    6. I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks. I have been given opportunity to ask questions before I sign. I voluntarily agree to testing for COVID-19.

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