Consent for COVID-19

Consent for COVID-19

Consent for COVID-19 Antigen Rapid Test

A.   I understand I will be tested utilizing the COVID-19 Antigen Test cassette kit through a nasopharyngeal swab. This kit has been authorized by the FDA under an Emergency Use Authorization
(EUA). Per the FDA, the intended use of this kit is to aid in identifying individual with an adaptive immune
response to SARS-CoV-2 (the virus that causes COVID-19) indicating present infection.
• This test has been authorized by FDA under an EUA for use by authorized laboratories;
• This test has been authorized only for the presence of SARS-CoV-2, not for any other viruses or pathogens; and
• This test is only authorized for the duration of the declaration that circumstances exist justifying the
authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of COVID-19 under Section 564(b) (1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.

B.   I authorize my test results to be disclosed to the County, State or to any other government entity as may be
required by law.

C.   I acknowledge that a positive Antigen test result is an indication that I must self-isolate and/or wear a mask or face covering in an effort to avoid infecting others and that I will contact my health care provider for further
assessment and testing. I agree I will seek medical advice, care and treatment from my personal healthcare
provider if I have any questions or concerns.

D.   I understand this testing facility is not acting as my medical provider and I assume complete and full
responsibility to take appropriate action with regards to my test results

E.   I understand that, as with any screening test, there is a potential for a false positive or false negative test

Electronic Signature

With my e-signature, I agree to indemnify, defend and hold harmless this facility and its officers, directors,
shareholders, employees, agents, representatives, successors and assigns from any and all claims, demands,
losses, liabilities, judgments, awards and costs (including attorney’s) fees arising out of or relating to the
administration/reading of this rapid test. I certify and affirm that I have read the “Fact Sheet for Recipients –
Emergency Use of SARS-CoV-2 Antigen tests during the COVID-19 Pandemic” dated April 28, 2020. I have
been given the opportunity to ask questions. I have received a copy of this informed consent. I voluntarily agree to this COVID-19 Antigen Rapid Test.

Test Results Notification


Your location data will be used to help identify you and allow us to offer you great products and services. Your consent is important for us to do this and you are not obliged in any way to share this information with us. Thank you