Informed Consent for COVID-19 Diagnostic Testing

  1. Authorization and Consent for Covid-19 Diagnostic Testing:
    I voluntarily consent and authorize Lab Express Inc. (“LXI”) to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test. I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample by my healthcare provider through a nasopharyngeal swab, oral swab, or other recommended collection procedures. I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and there may be a potential for false positive or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. I understand that it is my responsibility to know and request the correct COVID-19 test if ordering for travel reasons. Should I have question or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider.

  2. Patient Rights and Privacy Practices
    a) Notice of Privacy Practices and Patient Rights: LXI’s Notice of Privacy Practices describes how it may use and disclose your protected health information to carry out treatment, initiate and obtain payment, conduct health care operations and for other purposes that are permitted or required by law. To review a copy of your rights as a patient and LXI’s Notice of Privacy Practices please see attached. I acknowledge that LXI has provided me with a copy of LXI’s Notice of Privacy Practices.
    b) Disclosure to Government Authorities: I acknowledge and agree that LXI may disclose my test results and associated information to appropriate county, state, or other governmental and regulatory entities as may be required by law.

  3. Release
    To the fullest extent permitted by law, I hereby release, discharge and hold harmless, LXI, including, without limitation, any its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results.

    By selecting the ACKNOWLEDGEMENT during the registration process for COVID-19 Diagnostic Testing at LXI, I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I have been informed about the purpose of the COVID-19 diagnostic test, procedures to be performed, potential risks and benefits, and associated costs. I have been provided an opportunity to ask questions before proceeding with a COVID-19 diagnostic test and I understand that if I do not wish to continue with the collection, testing, or analysis of a COVID-19 diagnostic test, I may decline to receive continued services. I have read the contents of this form in its entirety and voluntarily consent to undergo diagnostic testing for COVID-19.