COVID-19 diagnostic testing

COVID-19 diagnostic testing, authorized by the Food and Drug Administration under an Emergency Use Authorization (EUA), will be used today. This test is meant for use in individuals with signs and symptoms compatible with COVID-19.

Please carefully read the following informed consent:

a. I authorize Terros Health to conduct collection and testing for COVID-19 through a nasopharyngeal swab.
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 continue to self-isolate in an effort to avoid infecting others.
d. I understand that Terros Health 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 can occur.
f. I acknowledge that I have been provided access to Terros Health’s Notice of Privacy Policy as found at

https://www.terroshealth.org/wp-content/uploads/2020/03/Patient_Documents_2020.pdf

I have been informed about the test purpose, procedures, possible benefits and risks, and I understand I can request a copy of this Informed consent. 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.

AGREEMENT FOR SELF-ISOLATION
The local health jurisdiction has determined that if you are suspected to have COVID-19 due to symptoms and testing, it is necessary to be placed in isolation in order to prevent the transmission of this infection. It is important for you to comply with this Isolation Agreement in order to protect the public’s health.

Thank you for agreeing to cooperate.
8. Please carefully read and comply with the following statements:
a. I understand that I may be infected with the virus causing COVID-19 and that I meet criteria for isolation.
b. I agree that if my COVID-19 test results are negative, I will remain isolated until at least 72 hours after
any symptoms have resolved.
c. I agree that if my COVID-19 test results are positive, I will remain isolated for 7 days from this day of testing OR until at least 72 hours after my symptoms have resolved, whichever is longer.
d. I agree that if my COVID-19 test results are negative, I will remain isolated until at least 72 hours after any symptoms have resolved.
e. I understand that if I am not isolated while ill, I could pose a substantial threat to the health of other persons.
f. I agree that I will not come into contact with any other person who is not isolated or ill due to potential COVID-19 infection.

 

I have been informed about the test purpose, procedures, possible benefits and risks and been given the opportunity to ask questions. I voluntarily agree to testing for COVID-19 and to self-isolation. Please enter name as agreement.

I have been informed about the test purpose, procedures, possible benefits and risks and been given the opportunity to ask questions. I voluntarily agree to testing for COVID-19 and to self-isolation. I AGREE AS A GUARDIAN TO THE UNDERSIGNED

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