I agree to give my consent for information registration and other data processing of my personal and medical information.
Patient & Contact Information
Prefer not to say
Symptoms within the last 14 Days
Sore Throat / Throat Pain
Shortness of Breath
Body Pains / Muscle Pains
Diarrhea with or without vomiting
Lack of smell or taste
Fever 37.8°C or higher
Have you had any unprotected close contact exposure to a person confirmed COVID-19 positive?
Unprotected close contact - being within approximately six (6) feet or two (2) meters from a person with COVID-19 for approximately five (5) minutes or longer and not wearing a face mask.
Within the last 14 days, have you traveled via airplane internationally or domestically?
Have you been hospitalized or taken to a quarantine facility for pneumonia or COVID-19?
Have you tested positive for COVID-19?
What is your reason for testing?
Felt Flu-like Symptoms
Exposure to a person/s positive for COVID-19
Have you had Rapid Antibody Test for COVID-19?
Have you had RT-PCR (Swab test)?
Vaccination against COVID-19
Are you vaccinated against COVID19?
Yes, fully vaccinated
Yes, first dose only
Brand of vaccine
Informed Consent (Please write down your initials after each statement.)
I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the WHO. I give my consent to have treatment done to me during this pandemic.
I'm aware that the virus is extremely contagious, is believe to spread by person-to-person contact, may be transmitted by contact through surface, and that it can stay in the air for up to 72 hours. I'm also aware that it is not always possible to identify persons who are COVID-19 positive. To protect myself, other patients and the clinic staff, I therefore agree that treatment options available to me are limited only to urgent care.
I recognize that the clinic is adhering to strict infection control protocol/s for my protection and as such, I agree to cover the fee/s that this entails.
However, given the nature of the virus, I understand that there is higher risk of becoming infected with COVID-19 by traveling to and from the clinic, proceding with the treatment/procedure/surgery, and/or by simply staying in the clinic. Should I contract the virus, I hereby agree that I shall not hold the clinic, owner/s, or its staff liable.
I'm also giving my consent, in accordance to IATF rules, for my identity to be revealed and contact information shared for possible contact tracing.