CovidTestEntry

Covid Test Inbound
Address
Address
City
State/Province
Zip/Postal
Country
Close Contact defined as within 6-ft for a total of 15 minutes or more over a 24- hour period
I, the above signed, have been informed about the test purpose, procedures, possible benefits, and risks, and I can request a copy of this informed consent. I acknowledge that tests may be self-ordered or ordered by a licensed medical professional, and that there is no guarantee of insurance coverage or payment. I authorize Island Drug/La Conner Drug to conduct collection and testing for COVID-19 through a nasopharyneal (NP), oropharyngeal (OP), mid- turbinate (MT), or anterior nares (AN) swab; or observe or direct alternative self-collection techniques. I authorize Island Drug / La Conner Drug, an associated lab, or an alternate provider to interpret and inform me of results. I understand that, as with any medical test, there is the potential for a false positive (test is positive but I do not have the infection) or false negative (test is negative but I do have the infection) COVID-19 test result. I authorize all documentation may be sent to providers (e.g., healthcare providers, collaborative providers, and insurance companies) for care, quality assurance, and billing purposes. I understand that test results are to be disclosed to the county, covered entity, or any other governmental agency as may be required by law (e.g., WAC 245-101) and that I will be available to be further contacted. I acknowledge that a positive test result is an indication that I must quarantine and/or wear a mask or face covering as directed to avoid infecting others. I understand that I should self-isolate while waiting for test results if I have had a recent exposure or experience any symptoms. I understand this test and Island Drug / La Conner Drug care does not replace treatment by my medical provider, and I assume complete and full responsibility to take the appropriate action with regards to my test results. I will seek medical advice, care, and treatment from my medical provider if I have questions or concerns or if my medical condition worsens. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19. I agree to electronic communication to receive my COVID-19 test results. (Only negative results may come via electronic means. Positive tests will result in a phone call and/or letter to the contact listed above).

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