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COPY OF COVID TEST CONSENT PAGE ENGLISH
COVID TEST CONSENT PAGE - ENGLISH
Total Care Work Injury Clinic COVID-19 Testing Consent Form
Covid-19 Consent Form
Covid-19 Test Form - Spanish
Name*
COVID Results*
Positive
Negative
Specimen Time*
Office Stamp Required*
The PCR Nasal Swab test detects the presence of virus and determines if you are currently infected with COVID. This test is for those with Covid symptoms such as cough or fever, although some people with COVID-19 have no symptoms. Results 48-72 hrs:
COVID-19 Sofia Antigen Nasal Swab The Sofia SARS Antigen is designed to detect proteins from the virus that causes COVID-19 in respiratory specimens, for example, nasal swabs. A positive result is highly accurate, but a negative result does not rule out infection. Results in 30min:
COVID-19 Serology Antibody IgG Blood Test The Serology Antibody test is to detect if you have been infected with COVID-19 in the past. The antibody test is for those who do not currently feel sick but want to find out if they have previously been infected and recovered from COVID-19:
About Accuracy of Medical Testing Medical Testing is not 100% accurate. Any test performed must be interpreted based on medical history and symptoms and should be reviewed with a physician who is knowledgeable in COVID-19 infection. Further, Premier is not the manufacturer or producer of any proffered testing kits/supplies. Therefore, Total Care cannot guarantee, represent, or warrant the reliability, accuracy, validity, results, or any other aspect of the test(s) supplied:
Acknowledgments a. I authorize Total Care personnel to collect samples for COVID-19 testing, either by nasal swab or blood draw. b. I authorize my test results to be disclosed to the County or State Health Department when it is required by law. c. I acknowledge that a positive PCR test is an indication that I must self-isolate and/or wear a mask or face covering to avoid infecting others. d. I understand that, as with any medical tests, there is a potential for inaccuracy, to either report a positive result when it was a negative, or vice versa. e. I understand that testing does not replace treatment by a medical provider. I agree I will seek medical attention or treatment if I have additional concerns or if my condition worsens, regardless of the test results. f. I consent to allow Total Care to email my COVID-19 test results to the email address documented below. g. (For employees sent by their employer for testing): I hereby and expressly authorize Total Care Work Injury Clinic to disclose my COVID-19 test results to my employer:]*
Initial:
Financial Policy – Use of Insurance for Testing and or Treatment Total Care accepts online reservations for patients who wish to use their private insurance or visits billed to their employer’s worker's compensation insurance. Total Care will attempt to authorize the visit in advance of your appointment, and make efforts to phone you in advance, at any number provided, in the event any foreseen issues or concerns arise. However, patients are responsible for any visits denied by insurance carriers. Denied visits will be billed to the patient at a rate of $160.00 for the PCR Nasal Swab test and $160.00 for the Serology Antibody test. By signing below, you agree to this financial policy and to reimburse for ANY denied visits either whole or in part.
Tests to be performed*
COVID Nasal PCR
COVID Antigen FIA
COVID Antibody (Lab or Rapid)
I have read, understand, and acknowledge all the above - Patient Electronic Signature/Consent*
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