Release for Abbott BinaxNow COVID-19 Antigen Test

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Rankin School District #98
COVID-19 Test

Email *

Name of person completing this release? *

Name of person being tested *

Today's date *

Birthdate of person getting tested

Address of person getting tested *

I understand that Dr. Reginald Bowman, D.O. NPI:1316101892 is the ordering physician. *

Yes

Section 4: Patient Consent
I request and authorize Rankin's CLIA-certified laboratory to perform one minimally invasive nasal COVID-19 test for myself or for my minor child on the date entered above. I understand that that test is at no charge.

Yes

Type your name below as signature of official release/consent for the COVID-19 Test to administered to myself or for my minor child.

A copy of your responses will be emailed to the address you provided.

Submit

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