RE-1 Valley School District BinaxNOW ONE TIME RAPID TEST CONSENT

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RELEASE OF INFORMATION AND INFORMED CONSENT TO COVID-19 TESTING. *This form must be signed prior to specimen collection*

Name: *

Student: School Attending and Grade *

Non-Student:

DOB: *

YYYY

Address: (include City, State and Zip) *

Phone Number: *

please carefully read each statement and check each box: *

1. I authorize this COVID-19 testing unit to conduct specimen collection and laboratory testing for COVID-19 through nasal swab, as ordered by an authorized medical provider or public health official.

2. I authorize my test results will be disclosed to the Northeast Colorado Health Department and Colorado Department of Public Health and Environment.

3. I acknowledge that a positive test result is an indication that I must self-isolate for 10 full days or as directed by the Northeast Colorado Health Department.

4. I understand that RE-1 Valley School District is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regard to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.

5. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.

6. I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks. 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.

Required

**The electronic completion of this box is considered an official signature.** Signature and date: *

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