I am at least eighteen (18) years of age. I voluntarily consent and authorize AMC, and their
partners, any of their respective officers, directors, employees, representatives and agents to
conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test for myself
and/or my child(ren) and/or my legal dependent(s) as applicable. I recognize that I need medical
services and I voluntarily consent to treatment by the medical staff of the practice, as deemed
necessary in their judgment.
I understand that the type of test I am signing up for is a COVID-19 molecular reverse-transcriptase
polymerase chain reaction [PCR] test to detect the presence of viral RNA. The test will consist of a
self-collected nasal swab, or in some cases a self-collected oral swab.
I understand that there are risks and benefits associated with undergoing a diagnostic test for
COVID-19. I understand that test results are not 100% accurate and there may be a potential for
false positive or false negative test results.
A positive molecular test for SARS-CoV-2 generally confirms the diagnosis of COVID-19; however, tests
may remain positive long after a patient is no longer infectious due to prolonged detection of RNA.
A negative test result may just mean that I was not infected at the time the test was done. I
understand that I could still become infected at a later point, so it is important to continue to
practice prevention measures such as physical distancing and washing my hands frequently. If I
continue to have symptoms associated with COVID-19, I will contact my medical provider.
I assume complete and full responsibility to take appropriate action with regards to my test results.
If I have questions or concerns regarding my results, or my condition gets worse, I agree I will
promptly seek advice and treatment from an appropriate medical provider.
I understand that the extent of the county's role will be determining whether the test is medically
appropriate. Should I receive positive test results, I will seek care from my own medical provider.
Having insurance is not required to receive a COVID-19 PCR test. If I have insurance information, I
have provided this, accurately and completely and understand this information will be used to bill
my insurance company for the cost associated with this test. I will not be charged for this test.
To the fullest extent permitted by law, I hereby release, discharge and hold harmless, the Orange
County without limitation, any of their respective officers, directors, employees, representatives
and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out
of or in connection with any act or omission relating to my COVID-19 diagnostic test or the
disclosure of my COVID-19 test results.
I understand and agree that my COVID-19 test results may be sent to me by text message, telephone or
email by a lab or third-party organization, and I authorize the disclosure of my COVID-19 test
results to such organization. I understand and agree that my COVID-19 test results may be shared
with a Health Information Exchanges (HIE). An HIE is a community-wide information system used by
participating health care providers to share health information about you for treatment purposes.
Should you require treatment from a health care provider that participates in one of these exchanges
who does not have your medical records or health information, that health care provider can use the
system to gather your health information in order to treat you. For example, he or she may be able
to get laboratory or other tests that have already been performed or find out about treatment(s)
that you have already received.
Your initial confirms that you consent to COVID-19 testing, and, if you have any of the symptoms, you
will isolate yourself from any other people until you receive a negative test result.