Preregistration Form – CovX Labs

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Covid-19 PCR Test Registration

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Booking Information:
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- Regular Registration
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- Rapid Antigen Test
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Appointment Day & Time*

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Payment Type*
- Self Pay - (Travel Testing) Credit Card/Debit Card/Paypal
- Cash Pay - Pay by Cash at time of Collection
- Insurance (DO NOT USE FOR TRAVEL OR EVENTS)
- CLS
Test Order Priority*
- Regular (Results delivered within 48 hours of collection)
- Priority (Results delivered within 24 hours of collection)
Notice: You will be asked to enter your credit card information after submitting this form if you selected "Self Pay".
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Patient Information:
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First Name:*
Last Name:*
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Address 2:
City:
State:
Zip:*
Phone:*
Insurance Information:
Insured relationship to patient
Insured First Name*
Insured Last Name*
Insured date of birth:*
Date Format: MM slash DD slash YYYY
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CovX Labs only accepts insurance patients who are seeking testing for diagnostic purposes. Patients must be experiencing Covid-19 symptoms or have had a potential exposure to Covid-19 to qualify for medically necessary diagnostic test.*
- I acknowledge that I am seeking a diagnostic test.
Consent:
Consent Section 2
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Consent Section 2
This text will be replace & populated with appropriate text from Life Hope Labs. This text will be replace & populated with appropriate text from Life Hope Labs. This text will be replace & populated with appropriate text from Life Hope Labs. This text will be replace & populated with appropriate text from Life Hope Labs. This text will be replace & populated with appropriate text from Life Hope Labs. This text will be replace & populated with appropriate text from Life Hope Labs.
Informed Consent Hidden
COVID-19 TESTING CONSENT FORM, RELEASE AND WAIVER OF LIABILITY <br><br> Please review this document carefully before you decide whether to sign. It is your voluntary decision whether to sign this form in order to participate in this testing. <br><br> I hereby volunteer to participate to be tested for COVID-19. This testing is voluntary, and I am not required to undergo this testing. This testing is not a health benefit and is not part of my health insurance or benefit plan. Summary I certify that I am requesting and consenting that a CovX Labs employee or contractor administer a COVID-19 test upon the above-listed patient. The test involves swabbing the nasal cavity using a cotton swab. The swab will be used to collect a specimen from the patient for analysis for possible COVID-19. The process will be as follows: A qualified healthcare provider will collect the specimen using specimen collection devices and methods that are authorized under applicable law. The health care provider will be dressed in a lab coat, wear a N95 mask or equivalent, and latex free disposable gloves. Gloves will be changed out between each collection. If the person has nasal congestion, they will be asked to gently blow their nose and clean the area before proceeding. Coronavirus does not live in the mucus so a clean airway is needed to obtain a viable sample. It is anticipated that two testing options will be available. First, for a nasopharyngeal specimen, the person will be asked to tilt their head back at about a 90 degree angle. The swab will be inserted into one of the nasal cavities and then continue into the nasopharyngeal area which is located at the far back of the nose. The second option is a mid-nasal specimen. For this option, the person will be asked to tilt their head back at about a 70 degree angle. While gently rotating the swab, a swab is inserted less than one inch into one or both nostrils (until resistance is met). The swab is rotated several times against the nasal wall and is typically repeated in the other nostril using the same swab. For either testing option, there may be some brief discomfort; it is not painful, but it is uncomfortable. The sample will be transferred to a tube; the person's name and date of birth will be written on the tube for identification. After the collection, the person may feel like they have to blow their nose or sneeze. It is possible to experience slight bleeding from the collection. There are no long-lasting effects from the collection procedure. Alternatives include not taking the test. Additional information about COVID-19, also called coronavirus, is available at the CDC website, including at https://www.cdc.gov/coronavirus/2019-ncov/index.html CovX Labs will complete the analysis of the patient's specimen and provide a result within approximately 24 to 36 hours of receipt into the laboratory. For those who are 18 years or older, test results will be provided directly to that person. For those who are under 18 years old, test results will be provided to such person's parent or legal guardian as listed below. Signature on a separate form authorizing release of the test results is also required. Positive, Negative and inconclusive results will be made available to the person (or to the person's parent or legal guardian if the person is under 18 years old) through a confidential, secure web-based link. An inconclusive result, according to the CDC, should result in a recollection as quickly as possible. All inconclusive results are retested at CovX Labs prior to reporting to mitigate the necessity of retesting. As a person 18 years or older, or as the parent or legal guardian of an person who is under 18 years old, I authorize CovX Labs to contact me via telephone in order to communicate a result for any reason. CovX Labs will provide contact information for those who wish to speak with a physician for immediate guidance on a positive result. I understand that positive COVID-19 test results will be communicated to public health authorities by CovX Labs, their contractors or employees, consistent with applicable law and public health guidelines. Consistent with public health guidelines, I understand that patients who have a positive COVID-19 test result will be directed to stay at home and quarantine consistent with CDC guidelines. General Recitals, Release and Disclaimer I fully understand and acknowledge that the purpose is to test for presence of the virus that causes COVID-19. I further understand and acknowledge that CovX Labs is performing the specimen collection, conducting laboratory testing and reporting the results only and that CovX Labs is not assuming the duty to diagnose or treat the patient or advise the patient on whether to seek medical attention. Health information pertaining to the patient's test and any follow up services provided by CovX Labs is governed by CovX Lab's HIPAA Notice of Privacy Practices, which has already been provided or made available to the patient by CovX Labs for review. I understand that the patient's health information will not be used by CovX Labs for Marketing or Sale purposes. (1)Assumption of Risk.I hereby assume all risks and dangers associated with the collection of the specimen, maintenance, testing and/or reporting of the person’s test results. I further assume all responsibility for any harm, losses and/or damages whether caused in whole or in part by any action or inaction of CovX Labs or their employees, agents, representatives, contractors, affiliated companies, parent company, members, owners, shareholders, partners, attorneys and/or by any other person (\"Releasees\"), except if caused by gross negligence or intentional misconduct. (2)Release.I hereby voluntarily agree to release, waive, discharge, indemnify and hold harmless the Releasees from any and all actual or potential claims, causes of action, damages, and/or losses which may arise out of or is in any way related to the person’s participation in this testing, except if caused by gross negligence or intentional misconduct. I agree the Releasees shall not be liable for any injury, harm, loss, expenses, or damages that arise or could arise in the future, except if caused by gross negligence or intentional misconduct. (3)Promise Not to Sue.I hereby voluntarily agree not to file a claim, lawsuit and/or other action against the Releasees on account of any injury, harm, loss, expenses and/or damages that may arise out of or otherwise be related in any way to the collection, maintenance, or testing of the person’s sample and/or reporting of the person’s results, except if caused by gross negligence or intentional misconduct. I further agree that the beneficiaries of the person’s estate, heirs and next of kin are legally bound by the foregoing agreement. (4)Governing Law and Severability.This Waiver and Release shall at all times be governed by the laws of the State of Georgia. All portions of this Waiver and Release are severable so that if any portion is deemed unenforceable, the remaining portions shall remain in full force and effect. Signature I have read this COVID-19 TESTING CONSENT FORM, RELEASE AND WAIVER OF LIABILITY carefully, and all my questions were answered to my satisfaction. Testing is requested and authorized as described above, and I agree to the above terms. If Individual is 18 years or older: CovX Lab Testing and Reporting Qualifiers A positive test result for 2019-nCoV indicates that the virus commonly referred to as COVID-19 is present in the patient’s body, and the patient is presumptively infected with 2019-nCoV and presumed to be contagious. Laboratory test results should always be considered in the context of clinical observations and epidemiological data in making a final diagnosis and patient management decisions. Patient management should follow current CDC guidelines. The CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel has been designed to minimize the likelihood of false positive test results. However, in the event of a false positive result, risks to patients could include the following: a recommendation for isolation of the patient, monitoring of household or other close contacts for symptoms, patient isolation that might limit contact with family or friends and may increase contact with other potentially 2019-nCoV infected patients, limits in the ability to work, the delayed diagnosis and treatment for the true infection causing the symptoms, unnecessary prescription of a treatment or therapy, or other unintended adverse effects. A negative test result for this test means that 2019-nCoV RNA was not found to be present in the specimen above the limit of detection. However, a negative result does not rule out 2019-nCoV infection at a subsequent time and should not be used as the sole basis for treatment or patient management decisions.A negative result also does not exclude the possibility of 2019- nCoV infection. When diagnostic testing is negative, the possibility of a false negative result should be considered in the context of a patient’s recent exposures and the presence of clinical signs and symptoms consistent with 2019-nCoV infection. The possibility of a false negative result should especially be considered if the patient’s recent exposures or clinical presentation indicate that 2019-nCoV infection is likely, and diagnostic tests for other causes of illness (e.g., other respiratory illness) are negative. If 2019-nCoV infection is still suspected based on exposure history together with other clinical findings, re-testing should be considered in consultation with public health authorities. The information contained in a test report is intended to be interpreted by a licensed physician or other licensed healthcare professional. This is of particular importance with positive results. The report is not intended to take the place of professional medical advice. Decisions regarding use of prescribed medications must be made only after consulting with a licensed physician or other licensed healthcare professional, and should consider each patient's medical history and current treatment regimen. Individuals should forward the positive results to their personal physician for follow up or, if they do not have a personal physician, they should contact a physician or local public health authority for appropriate follow up.
HIPAA Consent Hidden
Health Insurance Portability and Accountability Act ("HIPAA") Authorization <br><br> Please note: this form is to be signed by 1) an individual who is 18 years or older as of today’s date; or 2) the parent or legal guardian of an individual who is under 18 years old. <br><br> I have hired CovX Labs to conduct COVID-19 testing. I hereby authorize CovX Labs, and any of its subcontractors and employees, to disclose my COVID-19 test information and results (including but not limited to my name and contact information) public health authorities and any governmental entity that requires the reporting of COVID-19 results. The disclosure is for purposes of evaluating my health and to report test results as required by law. This testing is not a health benefit or part of a health benefit plan. This authorization will expire in one year. I may revoke this authorization at any time, in writing by certified mail return receipt requested to CovX Labs, Attn: Compliance Officer, 12225 World Trade Drive Suite A, San Diego, CA 92128. <br><br> I understand that this testing is voluntary, but because the testing is being conducted for the purpose of providing testing information testing is conditioned on the signing of this authorization. However, no treatment or benefits payment, enrollment or eligibility is conditioned on the signing of this authorization. I also understand that revoking this authorization will not have any effect on actions already taken in reliance on this authorization before the revocation is received. If the person or entity to whom my protected health information is disclosed is not a health care provider or health plan covered by the Federal privacy regulations, the protected health information they receive may be further used or disclosed by them and may no longer be protected by the Federal privacy regulations.
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