I voluntarily consent and authorize TotalWellness to conduct collection, testing, and analysis for the purposes of a COVID-19 antigen test. I acknowledge and understand that my COVID-19 antigen test will require the collection of an appropriate sample through a nasopharyngeal swab or anterior nasal swab. I understand that there are risks and benefits associated with undergoing an antigen test for COVID-19 and there may be a potential for false positive or false negative test results. Any results I receive are for informational purposes only and do not constitute a medical diagnosis. I assume complete and full responsibility to seek and obtain medical and other advice relating to this testing and any results I receive. 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
I consent to receiving email, text messages, and phone calls at the email address and phone number provided by me. My results may be reported to me through any of the foregoing means or any other reasonable mechanism, including text messages or web-based applications. I understand that my results and the information provided by me may be reported to the ordering physician, my employer, any of my or their designees, and public health authorities as required by law. My results and the information provided by me may also be used by TotalWellness for internal and industry research purposes.
I expressly waive, release and forever discharge for myself, my heirs, estate, executors, administrators, successors and assignees, Vaccination Services of America, Inc. d/b/a TotalWellness and its employees, owners and representatives, as well as my employer or any other company involved with this event and their agents, representatives, employees, successors, assignees, governing bodies, and advisory committees (collectively, “Releasees”) from any and all claims, demands, actions and causes of action, now known or hereafter known in any jurisdiction throughout the world, on account of injury, death or property damage arising out of or attributable to my participation in this testing, whether arising out of the negligence of TotalWellness or any Releasee or otherwise. I further agree to indemnify, defend and hold harmless the Releasees from any litigation expense, attorney fees, or claim for personal injury in connection with my participation in this testing.
I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form along with the TotalWellness Privacy Practices Notice available at https://www.totalwellnesshealth.com/privacy-notice. I have been informed about the purpose of the COVID-19 antigen test, procedures to be performed, potential risks and potential benefits. I have been provided an opportunity to ask questions before proceeding with a COVID-19 antigen test and I understand that if I do not wish to continue with the collection, testing, or analysis of a COVID-19 antigen test, I may decline to receive continued services.
Please Answer: Have you had any of the following symptoms in the last 14 days?