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Patient Consent Form

Please take a moment to fill out the form.


Please carefully read the permission form. I give Impeccable Pre-Hire permission to do a nasopharyngeal or anterior nare swab for free or Rapid COVID-19 testing. The results of a PCR test could take up to 3 business days to come back. I know that a positive test result means I need to stay away from other people PER CDC GUIDELINES so I don't harm them. I know that if I don't have insurance, I can only get a COVID-19 test with cash, debit/credit cards, or flexible spending cards.I know that the reference lab that did my PCR tests will send me a bill. I understand that if I have health insurance, my COVID-19 PCR tests will be billed to my insurance company or to Impeccable Pre-Hire under the Patient Care Act if I don't have health insurance. Since COVID-19 testing is paid by my insurance, I know that there are no co-payments or deductibles. I know that Impeccable Pre-Hire is not my main provider of health care. Testing doesn't replace the care I get from my doctor. I take full and total responsibility for figuring out what to do about my test results. I agree that I will talk to my Primary Care Provider about any questions or issues I have or if my condition gets worse. I know that there is a chance that a medical test could give a false positive or false negative report.

I, the undersigned, have been told about the goal of the test, how it will be done, any possible benefits and risks, and how I can pay for it. I was given the chance to ask questions before I signed, and I've been told that I can always ask more questions. I agree to take the COVID-19 test on my own.

COVID 19 Questionnaire- Please fill out completely

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