Registration and Informed Consent DRAFT Please Complete and Submit Prior to Arriving at the Testing Site *If you are currently experiencing chest pain or shortness of breath that began suddenly and is worsening, please call 911 immediately! Respiratory Epidemic Virus Testing Registration First Name* Last Name* Date of Birth* Email Address* Preferred Phone Number* Which of the following are you currently experiencing? Select all that apply* CoughFever of 100.4 or higherShortness of breathNasal congestion/runny noseSore throatHeadacheRashChange/loss of sense of smell/tasteFatigueMuscle achesChest painRecent confirmed COVID-19 exposureRecent suspected exposure to COVID-19None of the above If you are experiencing any of the above, when did that begin? Do you have any of the following conditions?* DiabetesHypertensionAsthmaCOPD/EmphysemaCancer/ongoing chemotherapyNone Are you currently pregnant?* YesNoNot applicable Who is your primary care provider? Phone Number I do not have a primary care provider Important! Please Read The test will be performed at JetHawks stadium. Please arrive within 10 minutes of your appointment time. Upon arrival, follow the direction of the safety officers and stay in your car. You will be asked to show your identification prior to the test being administered. The sample will be obtained via a self administered anterior nasal swab performed by you under the direction and supervision of a trained worker at the site. Please keep your mask over your mouth while you obtain the sample. The sample will then be tested for COVID-19, Influenza A and Influenza B during a single analysis with the Sofia2 Analyzer. The test is rapid and typically takes approximately 15 minutes. While the test itself is very quick, please understand that it may take up to 24 hours to receive your results as we are running many tests each day. Please note that all individuals for which the test does not detect COVID-19, Influenza A or Influenza B will receive an email within 24 hours of testing with those results and further information. Individuals for who the test detects either COVID-19 or Influenza A or B will receive an email and may receive a phone call within 24 hours of testing with results and further information. The call will likely come from (661)947-7100, please answer this call. During this call you will be offered to schedule a follow up telemedicine visit to further discuss the results and precautions you need to take. This telemedicine visit will not be covered by the cost of the test. You may use certain PPO insurance, HSA card, or credit/debit card to pay for the visit over the phone at the time of scheduling, and will be given a $10 discount for telemedicine visits directly related to follow up on this test. If you have questions before your test, please ask at the testing site. For questions after your test, please wait for your followup email or phone call. If you have not received your results 24 hours after your test was administered, please email or call (661)947-7100. The following sections must be completed prior to submitting this form. If any section is left incomplete, your test will not be performed. I understand that the COVID-19, Influenza A, Influenza B combination test has been ordered because I stated that I have symptoms, exposure or situation consistent with needing a test. I understand that I have not seen a medical provider and the decision to perform the test was made solely on my reporting. I understand that the results of this test are not a diagnosis of a condition, but simply results of what was or was not detected through analysis of the sample. I understand that in order for a diagnosis to be made, my test results must be interpreted in light of a thorough history and examination by a medical provider. I also understand that for the best outcome, it is my responsibility to follow up with a medical provider (preferably via telemedicine) within 24-48 hours of the test. I will hold harmless the City of Lancaster, Garrison Family Medical Group and their staff/volunteers in the event of any adverse outcome as a result of the test. I understand that results are reported to the CDC and LA County Department of Public Health as part of the measures the Country and the County of LA are taking to monitor and manage the current pandemic. This is not an optional reporting as every testing center or laboratory is required by mandate to report these results. I understand that any follow up care is a separate fee and will either be billed to my insurance (PPO insurance only) or to me and that payment for services is required prior to the appointment. I also understand that follow up is recommended but not mandatory and that I may choose to follow up with a provider of my choosing but that Garrison Family Medical Group is offering Telemedicine follow up as a convenience. I understand that if I test positive for COVID-19, Influenza A or Influenza B, it is my responsibility to inform any and all contacts with whom I have had “close contact” as the test site and the follow up visit do not include this type of contact tracing. I also understand that it is my responsibility to answer the phone if or when the contact tracers from LA County Dept of Public Health reach out to me, and to answer their questions as honestly as I am able. I understand that a result of “Undetected” does not guarantee that I am not currently infected with COVID-19, Influenza A or Influenza B, only that none of the above named viruses were detected in the sample that was taken. I also understand that even with a result of “undetected,” I may be able to transmit COVID-19, Influenza A or Influenza B and that it is my responsibility to follow the appropriate guidance from the CDC, LA County Dept. of Public Health, LA County Health Officer and any medical professionals I speak with in order to best prevent the transmission of Respiratory Epidemic Viruses. I authorize Garrison Family Medical Group and it staff as well as those working at or on behalf of the Garrison Family Medical Group + City of Lancaster Respiratory Testing Site to call or email me as necessary. I understand that all measures are taken to protect my confidentiality, however electronic communications are not guaranteed to be secure. I also understand that emails I may receive are not encrypted. Informed Consent for COVID-19 Antigen Testing I authorize Garrison Family Medical Group, it’s staff and affiliates to conduct collection and testing for COVID-19, Influenza A and Influenza B through a nasal or nasopharyngeal swab and fluorescent immunoassay analysis, as ordered by a medical provider. I authorize my test results to be disclosed to the County, State and CDC as necessary. I have received patient information about the testing procedure and understand that the risks of the nasal or nasopharyngeal swab include but are not limited to: pain, epistaxis (bloody nose), respiratory tract irritation (coughing, sneezing, watery eyes, shortness of breath), or rupture of a nasopharyngeal blood vessel. I understand that these potential risks are mostly temporary and very rare, but I accept these risks voluntarily and will hold harmless Garrison Family Medical Group and any Testing Site workers should any of these outcomes occur. I understand that the benefits of testing include but are not limited to: peace of mind, ability to properly quarantine/isolate and prevent further spread, seek and obtain appropriate medical care, and inform close contacts of potential exposure so that they may also quarantine or isolate appropriately. I acknowledge that a positive antigen test result is an indication that I must continue to self-isolate in an effort to avoid infecting others. A positive test may result in extended quarantine and recommendation for additional tests. I understand that testing does not replace treatment by a medical provider. 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 a medical provider if I have questions or concerns, or if my condition changes or worsens. I understand that medical treatment before/during/after my testing may result in the following: hospitalization that may require medical therapy, intensive care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications and the risk of death. I understand that COVID-19, Influenza A or Influenza B infection may results in the following: short term disability, long term disability, permanent partial or complete disability. I understand that COVID-19, Influenza A, and Influenza B carry with them additional risks, some or many of which may not currently be known. I understand that, as with any medical test, there is the potential for false positive or false negative results. I also understand that I may be exposed to or contract COVID-19 after this sample is taken, resulting in a future positive test or symptoms of disease. I understand that there is a $75 cost associated with testing. I understand that I am responsible to pay this fee prior to administration of the test, unless I live within the City Limits of Lancaster, or am an employee of one of the affiliated employers. I understand that there is further cost associated with medical visit following my test. I understand that if I choose to follow up with Garrison Family Medical Group via a telemedicine visit, that cost is $110 dollars. GFMG will bill insurance first (PPO only) if provided, and any remaining balance after insurance will be my responsibility. I recognize that the City of Lancaster, Garrison Family Medical Group and all the staff at the testing center and GFMG office are closely monitoring this situation and have put in place preventative measures to reduce the spread of COVID-19, Influenza A, Influenza B and other infectious diseases. I, the undersigned, have been informed about the test purpose, procedures, cost, possible benefits and risks, understand that I can ask other questions any time. I voluntarily agree to receive the COVID-19, Influenza A and Influenza B combination antigen test. If you would like a copy of the signed consent, please call (661)947-7100 and request a copy. Signature of individual being tested or legal guardian* Today's Date* Relationship to individual being tested
