2019-Novel Coronavirus (COVID-19) Testing Consent
By signing below, I understand, agree, certify, and authorize the following:
I am the patient named below or I am the parent or legal guardian (if the patient is a minor or dependent) of the patient named above.
I authorize Soler-Baillo Plastic Surgery (SBPS, Inc.) to collect a specimen for COVID-19 Antibody testing which I understand only tests for the presence of Antibody and not for active Covid-19 infection.
I understand the test collection procedure and possible risks:
The test may cause aching and bruising at puncture site
The test may be uncomfortable
Some bleeding after the collection may occur, but is not expected
Failure to obtain adequate sample may result in inaccurate test results
SBPS Inc. will provide the kits to perform the tests. (SBPS) staff will collect the specimen and interpret the results of my, my child's, or dependent's specimen. I give permission for SBPS members to perform the test.
I understand the COVID-19 Antibody test is not 100% accurate, cannot be used to rule out an infection, and a negative test does not preclude the presence of COVID-19.
I understand that results are generally available within 3-10 minutes but may be longer due to lab volume and processing times.
I understand a SBPS provider will contact me only at the number provided on this consent whether the result is positive or negative. Positive results for COVID-19 antibodies are reported to the patient and they should then go to a State-sponsored site and get further testing.
I understand that SBPS will be responsible for providing testing results, interpreting test results, explaining testing limitations, and facilitating any additional diagnostic or clinical services. As well as collecting the fee for such procedure.
I understand that this test has been authorized by Food and Drug Administration under an Emergency Use Authorization. This test has been authorized only for the presence of IgM and IgG antibodies against SARS-CoV2, not for any other viruses or pathogens.
I Release from Liability SBPS and waive my right to sue SBPS, their employees, officers and agents from any and all claims including any negligence and any economic loss from proceeding with this exam and its results.
Please verify that you are human
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