Healthcare Covid-19 Patient Consent Form

Healthcare COVID-19 Patient Consent Form

Patient Information

Insurance Information

Medical History

Are you currently pregnant?   Yes    No

Are you immunocompromised or taking immunosuppressive medication?   Yes    No

Consent for COVID-19 Testing and Vaccination

I hereby authorize the healthcare provider to perform COVID-19 testing and/or vaccination as indicated below. I understand the nature of the service(s), the intended benefits, and common risks associated with specimen collection and vaccination.

Select the services you consent to:
COVID-19 Diagnostic Testing (viral test)
COVID-19 Antibody Testing (serology)
COVID-19 Vaccination

Specimen collection method (if applicable):   Nasal / Nasopharyngeal swab   Saliva   Blood draw

Risks and common adverse reactions: I understand that testing may cause temporary discomfort including nasal or throat irritation, bleeding, or bruising. Vaccination may cause local pain, swelling, redness, fever, fatigue, headache, muscle pain, or allergic reaction. Serious adverse events are rare. I acknowledge that no guarantee of benefit is made and that testing and vaccination do not eliminate all risk of infection or transmission.

Alternatives: I have been informed of alternatives, including not receiving testing or vaccination, and the possible consequences of refusing the recommended service(s).

Authorization to Use and Disclose Health Information

I authorize the release of my COVID-19 related health information and test/vaccination results to public health authorities, healthcare providers involved in my care, and entities required by law for disease reporting. Such disclosures may include my name, date of birth, diagnosis, test results, vaccination status, and relevant medical history.

I consent to receiving test results and vaccination follow-up communications via the following (select all that apply):
Phone    Text Message    Email   

I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws.

I consent to the storage of residual specimens for quality assurance and limited research purposes:   Yes    No

Voluntary Consent and Revocation

I acknowledge that this consent is voluntary. I may revoke this authorization at any time by providing a written notice to the facility except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect any disclosures made prior to receipt of the revocation.

Certification

By signing below I certify that I am the patient or the patient's legally authorized representative. I have read (or had read to me) the information on this form, all my questions have been answered, and I understand the nature, risks, benefits, and alternatives of the procedures or services authorized above. I authorize the performance of the selected services and the use and disclosure of my health information as described in this form.

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