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COVID-19
Antigen Testing
COVID-19 Antigen Testing
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Full name*
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COVID-19 TESTING QUESTIONNAIRE
1
COVID-19 TESTING
QUESTIONNAIRE
2
INFORMED CONSENT
FOR RAPID
COVID-19 TESTING QUESTIONNAIRE
Name
Booking Date
Booking Time
Email
Yes
No
First test?
Symptomatic as defined by CDC?
Employed in healthcare?
Hospitalized?
ICU?
Resident in congregate care setting?
Pregnant?
Please read the informed consent carefully.
The following has been explained to me, and I agree:
I will have a rapid Covid-19 test performed at Graceful In Home Healthcare.
A positive test is considered diagnostic, and a confirmatory testing will be needed and a referral will be made to a third-party lab.
In cases where symptoms are strongly suggestive of Covid-19, a confirmatory test referral will be made to a third-party testing of patient choice.
In case I don’t get notified within 72 hrs., I will call Graceful In Home Healthcare at 402-387-7933 for my test result.
By law, the Nebraska Department of Health and human Services DHHS will be notified that I was tested, and what the test results are.
In addition, I have been shown a copy of the instructions of what I have to do following testing, I have read those discharge instructions thoroughly, and I Agree to comply with those instructions. I agree to self-quarantine until I am cleared.
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, as the recommended collection procedures.
I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and as with any medical test, 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. 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.
***I understand that Rapid COVID-19 testing is available for cash/card pay only and my insurance will NOT be billed for Rapid COVID test.
Name:
Today's Date and Time:
Witness Name:
Witness Signature:
Witness Date:
Witness Time: