COVID-19 TESTING INFORMED CONSENT

Please carefully read and sign the following Informed Consent:

Introduction: SARS-CoV-2 (COVID-19) is a respiratory illness that can start as fever and cough. It may go on to pneumonia in some people SARS-CoV-2 (COVID-19) seems to spread by close person to person contact. This can occur when a person who is sick with SARS-CoV-2 (COVID-19) coughs or sneezes onto themselves, other people, or nearby surfaces. Droplets from the cough or sneeze can travel a short distance through the air and land on the mouth, nose, or eyes of persons who are nearby. The virus also can spread when a person touches a surface or object with infectious droplets and then touches his or her mouth, nose, or eye(s). It also is possible that SARS-CoV-2 (COVID-19) can be spread through the air or by other ways that we do not yet know about.

It is important to test for SARS-CoV-2 (COVID-19) so that public health efforts could quickly identify a case and limit its spread. The test detects If you have SARS-CoV-2 (the virus that causes COVID-19) at the time of the test only. It does not test for immunity or if you had the virus in the past.

Informed Consent: I hereby knowingly and freely declare, undertake, and warrant that:

1. I authorize this COVID-19 testing unit (Detoxicare Molecular Diagnostics Laboratory, Inc.) or Testing Unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab and/or oropharyngeal swab.
2. I understand that to do this test, samples may be taken that are like samples that are normally taken for testing when you are sick. These samples may include nasal swab or aspirate, throat swab, sputum, blood, serum, plasma or stool. The nasal swabs are taken by placing one small swab into the back of one's nose for at least five (5) seconds. The throat swabs are taken by placing one small swab into the back of one's throat for at least five (5) seconds. These tests do not usually hurt but may cause discomfort. Sometimes, they make people gag, cough or get a bloody nose, or the swab stick may break which might be lodged in the nose or swallowed.
3. I understand that the Testing Unit is not acting as my medical provider, that this testing does not replace treatment by a medical provider, and I assume complete and full responsibility to take appropriate action about my test results. 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 worsens. A positive test result is an indication that must self-isolate and/or wear a mask or face covering as directed to avoid infecting others.
4. I authorize the Testing Unit to disclose my test results to (my employer or principal) and the Department of Health (DOH), including to the local government unit or other government agencies or instrumentalities as may be required by law, ordinance, rule or regulation.
5. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. Hence, a repeat swabbing may be required for cases that are deemed inconclusive.
6. I understand that, as with any medical test, there are certain inherent risks associated with having my nasopharyngeal swab and/or oropharyngeal swab. I hereby consent for myself, my heirs, executors, administrators, assigns, or personal representatives, and knowingly and voluntarily agree to have my sample drawn and analyzed by the Testing Unit and hereby waive any and all rights, claims, or causes of action of any kind whatsoever arising out of my participation in this activity, and do hereby release and forever discharge the Testing Unit, including its officers, directors, employees, agents and representatives from any physical or psychological injury, Including but not limited to illness, paralysis, death, economical or emotional loss, that I may suffer as a direct result of my participation In this activity, including traveling to and from any location related to this activity. If I should require medical care or treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.
7. I, the undersigned, have been informed about the purpose of the test, procedures, possible benefits and risks, and I have received a copy of this Informed Consent which is written in a language, I know, speak and understand. I have been given the opportunity to ask questions before I sign and have been told that can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.