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Patient Pre Registration Form

Please fill your basic information

Exactly same as on your INSURANCE CARD
Exactly same as on your INSURANCE CARD

Informed Consent for COVID-19 Testing

Please carefully read the following informed consent:

  • 1. I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab, oropharyngeal swab, and/or saliva sample as ordered by an authorized medical provider or public health official.
  • 2. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.
  • 3. I acknowledge that a positive test result is an indication that I must continue to self-isolate in an effort to avoid infecting others.
  • 4. I understand that, as with any medical test, there is the potential for false positive or false negative test results.
  • 5. I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks. 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.

Informed Consent for Email Communication of Health Information

  • 1. I understand that I may request that we communicate with you via unencrypted electronic mail (email). Your health is important to us and we will make every effort to reasonably comply with your request to receive communications via email. However, we reserve the right to deny any request for email communications when it is determined that granting such a request would not be in your interest.

  • 2. Risk of using email to send protected health information, includes, but are not limited to:

    a. Risk of Unauthorized access by a 3rd party.

    b. Unique difficulty in verifying the sender.

Patient Consent to COVID- 19 Testing, Telemedicine and Unencrypted Email Communication

By checking the box below, you acknowledge your recognition and understanding of the risks of COVID-19 testing, participation in telemedicine, and receiving unencrypted email communication of your health information, and are hereby consenting to all of these despite the stated risks. All clinically relevant messages may be incorporated into your medical record.

I authorize ASAP Results LLC to request, use or disclose my protected health information with other covered entities involved in my care, including laboratories, and for reporting purposes.

By checking the box below, you also acknowledge that you have the choice to receive communications via other secure means such as by telephone. You agree to hold ASAP Results LLC and its directors, officers, employees, agents harmless for unauthorized use, disclosure, or access of your protected health information sent to the email address you provide.

Patient Parental Consent for Routine Testing.

By checking the box below, you also acknowledge that your child may, can and will receive routine COVID-19 and Flu testing in the absence of your presence to prevent a potential outbreak. You authorize for these services to be billed to your medical insurance provider.