AUTHORIZATION AND CONSENT FOR COVID-19 TESTING
1. Authorization and Consent for Covid-19 Diagnostic Testing:
I voluntarily consent and authorize MobileVAX to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test. I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample through a nasal swab. I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and there may be a potential for false positive or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have question or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider.
2. Patient Rights and Privacy Practices
All results are confidential and protected under HIPAA and FERPA. The parent/legal guardian will receive the results of your child. The (Illinois Department of Public Health) and Principal of Instituto Health Sciences Career Academy High School will also be notified of the results.
To the fullest extent permitted by law, I hereby release, discharge and hold harmless, Mobile VAX and Instituto Health Sciences Career Academy High School, including, without limitation, any 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.
4. Consent For Testing
By selecting the ACKNOWLEDGEMENT during the registration process for COVID-19 Diagnostic Testing at UMC, I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I have been informed about the purpose of the COVID-19 diagnostic test, procedures to be performed, potential risks and benefits, and associated costs.