ANTIGEN TEST REGISTRATION IMPORTANT: DO NOT TAKE THE ANTIGEN TEST UNTIL INSTRUCTED TO DO SO DURING A VIDEO OBSERVATION CALL FOR MEDICAL SUPERVISION. We provide this service through Zoom Conferencing. Currently the available Zoom observation schedule is as follows: Monday - Friday 09:00am - 11:00am EST and 4:00pm - 7:00pm EST Saturday - Sunday 12:00pm - 3:00pm EST WATCH THE DEMONSTRATION VIDEO BELOW WHEN YOU ARE READY TO TAKE THE TEST, PROCEED TO REGISTER. AFTER YOU COMPLETE REGISTRATION WE WILL PROVIDE YOU WITH A ZOOM LINK TO COMPLETE THE TEST PROCESS. YOUR TEST MAY BE INVALIDATED UNLESS THIS PROTOCOL IS FOLLOWED. Name of the Person Taking Test* First Last DOB of the Person Taking Test* Date Format: MM slash DD slash YYYY Is this person a minor child?*YesNoYour Name (Parent / Legal Guardian) First Last Your DOB (Parent / Legal Guardian)* Date Format: MM slash DD slash YYYY Statement of Authorization* I certify that I am the parent / legal guardian and “personal representative” of the minor child and am authorized to exercise the minor’s HIPAA Privacy Rule rights with respect to protected health information (PHI).Signature* Email*This is to be sure we provide results to the correct person. THIS IS WHERE TEST RESULTS WILL BE SENT TO. Enter Email Confirm Email Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)* I hereby authorize Reliant Health Services LLC and GetTestedNow.com to use and/or disclose my (or for the minor child if applicable) protected health information (PHI). This authorization for release of PHI covers all screening questions and answers and all SARS-CoV-2 Test Results. I also understand this PHI may no longer be protected by federal or state law. I authorize for my results to be delivered by email. I am aware that these are not secure means of communication and that there is a risk that my protected health information could be accessed by unauthorized third parties. I understand and agree to the statements above and the Privacy Policy found at https://gettestednow.com/privacy-policy/. In the past two weeks what has been your exposure to COVID-19?* I’ve had close contact with someone who has been diagnosed with or presumed to have COVID-19 I’ve had close contact with someone who is sick but has not been diagnosed with COVID-19 I live or work in a congregate setting where people reside, meet, or gather in close proximity such as a healthcare setting, office building, homeless shelter, assisted living facility, group home, prison, detention center, school, or workplace I’ve had no known exposure Are you currently experiencing any of these symptoms? (Select all that apply)* Fever or chills Dry cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache Loss of sense of taste/smell Sore throat Congestion Nausea or vomiting Diarrhea Generally not feeling well Blue-colored lips or face None of these apply to me Do any of the following conditions apply to you?* I am 65 years of age or older I am pregnant I am very overweight or obese (BMI ≥40) I have a chronic condition (e.g. diabetes, high blood pressure, kidney disease or on dialysis, liver disease, lung disease, etc.) I have heart disease (e.g. previous heart attacks, heart failure, etc.) I regularly use tobacco or nicotine products (e.g. cigarettes, e-cigarettes, vapes, hookah, etc.) I have a condition that affects my ability to cough (e.g. had a stroke) I have a condition that weakens my immune system or makes it harder to fight infections (e.g. AIDS, cancer, lupus, rheumatoid arthritis, solid organ or bone marrow transplant, etc.) I am taking medication that weakens my immune system (e.g. steroids, chemotherapy, immunologics, etc.) None of the above apply to me. Attestation of NO Positive SARS-CoV-2 (COVID-19) Results in 90 Days* I attest that I have NOT tested positive or recovered from COVID-19 in the last 3 months (90 days),Signature*Unique ID for VerificationEmailThis field is for validation purposes and should be left unchanged.
