I voluntarily consent and authorize Vitality Urgent & Primary Care to conduct the 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. Should I have questions or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider or contact Vitality Urgent & Primary Care for consultation.
I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.
I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others.
I understand the testing unit is not acting as my primary medical provider, this testing does not replace treatment by my primary medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my primary medical provider if I have questions or concerns, or if my condition worsens.
I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.
Pre-Travel and Corporate Covid-19 Testing Disclaimer
I understand that Vitality Urgent Care will not be submitting a bill to my insurance and that my private payment services will not factor into my insurance plan’s maximums.
I understand that I am not using insurance for these services for testing services wit Vitality Urgent Care. I freely choose to self-pay for COVID-19 services and understand the associated clinic and partner laboratory testing policies.
If I have insurance coverage and am choosing not to use it, I am aware that there may be other providers who are may be in network with my insurance company, and that if I were to see those providers, some/all of my bill could be covered by insurance benefits.
Vitality Urgent Care partnered with multiple Clinical Laboratory partners to facilitate COVID 19 RT-PCR testing Services and Results Reporting. Vitality Urgent Care Provides referrals and event coordination but does not have direct ownership in Clinical Laboratory partners.
