This consent provides Rivertowns Pediatrics with your permission to perform a rapid COVID-19 screening procedure, as you have requested. By signing below, you are indicating that you voluntarily consent to this procedure for the detection of COVID-19. The test being administered involves a nasal swab that will be tested to indicate the potential presence of COVID-19.
Rivertowns Pediatrics only performs molecular NAAT testing either with PCR or molecular RNA.
These tests have been approved by the FDA under Emergency Use Authorization, however, this test alone may not be sufficient to detect or rule out the possibility that you have been exposed to or are infected with COVID-19. You should carefully monitor your own symptoms and, notwithstanding the results of any testing, you must stay home and consult with your physician if you experience symptoms of COVID-19.
The New York State Department of Health requires Rivertowns Pediatrics to report to it the results of your test, whether positive or negative. By signing below, you consent to the disclosure of such information. By signing below, you agree to release and waive any claim arising from your election to receive this voluntary screening that may arise against Rivertowns Pediatrics and its designated medical providers and staff members. Additionally, you agree to release and waive any claim that might arise against Rivertowns Pediatrics and its designated medical providers and staff members for any risks, side effects, or complications resulting from the testing.
Rivertowns Pediatrics is not responsible for any letters of clearance for return to work, school, or event for non-members.
Rivertowns Pediatrics is not responsible for any copays or deductibles owed to your insurance company. Rivertowns Pediatrics is not responsible for any reimbursements for any testing charges. Please contact your insurance company in regards to any billing.
Please refer to your own physician for any additional paperwork and treatment.