ANTIGEN TEST REGISTRATION Instructions IMPORTANT: You must pre-register your test ONLY within 24 hours of use. Registrations expire after 24 hours - registrations beyond this timeframe will require re-registration which may cause a delay. Each person being tested must have their test registered prior to observation - the email provided in this registration will determine where results will be sent. DO NOT OPEN / TAKE THE ANTIGEN TEST UNTIL INSTRUCTED TO DO SO as your test requires medical video observation for travel. After test registration, you will receive a Zoom link with further instructions on completing the test observation process. Supervised Medical Observation Hours Monday – Friday 09:00am – 7:00pm EST Saturday 12:00pm – 3:00pm EST – Closed Sundays Groups of up to 10 may test together on a single zoom session once all persons have registered. Name of the Person Taking Test* First Last DOB of the Person Taking Test* MM slash DD slash YYYY Is this person a minor child?* Yes No Government Issued ID Number* Type of ID* Passport Drivers License Military ID NEXUS, SENTRI or FAST Other TSA Compliant ID Your Name (Parent / Legal Guardian) First Last Your DOB (Parent / Legal Guardian)* 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 have recovered from COVID-19 in the last 3 months (90 days),Attestation of Clearance after Recovery from SARS-CoV-2 (COVID-19) by viral test. I attest that I have recovered from COVID-19 in the last 3 months (90 days), or the time period specified in current CDC guidance, after having previously tested positive for SARS-CoV-2 and have been cleared for travel by a licensed healthcare provider or public health official.Signature*Unique ID for Verification CommentsThis field is for validation purposes and should be left unchanged.
