RapiFast®

Patient Information and Consent

A. I authorize RapiFast to conduct collection and testing for COVID-19.

B. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.

C. I acknowledge that a positive test result is an indication that I must self-isolate in an effort to avoid Infecting others.

D. I understand that I am not creating a patient relationship with RapiFast by participating In testing. I understand the testing unit is not acting as my medical provider. Testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or If my condition worsens.

E. I understand that as with any medical test, there Is the potential for false positive or false negative test results.

F. I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks.

I have been given the opportunity to ask questions before I sign, and I have been told that I can ask other questions at any time. I voluntarily agree to testing for COVID-19.

    Test Appointment Day* (MM/DD/YYYY)

    Gender*

    Date of birth* (MM/DD/YYYY)

    I have read the consent form and i accept the terms

    Guardian?

    Guardian Name (Leave blank if not a Guardian)

    Relationship to Patient*

    Signing Date* (MM/DD/YYYY)

    Signature*


    You can use your mouse, or finger if you are on your tablet or phone to sign.