Register COVIDBLOCK Antibody Test "*" indicates required fields Instructions IMPORTANT: You must pre-register your test ONLY WITHIN FOUR (4) HOURS OF TESTING. 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 TEST UNTIL INSTRUCTED TO DO SO as your test requires medical video observation to be valid. After test registration, you will receive a tele-health session link with further instructions on completing the test observation process. Important* I understand that this test does WILL NOT tell if me if have an active COVID-19 infection. I understand this test CANNOT determine whether or not i can spread the virus to others. I understand and agree that this test is not for diagnostic purposes or to confirm immunity. 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/. Do you think you’ve been infected with covid-19?* Yes – I’ve had a positive test Yes – my doctor suspected, but I wasn’t tested Yes – I suspected, but I wasn’t tested No, I don't think so. Have you received one or more doses of the covid-19 vaccine?* Yes No What was the date of your last COVID-19 vaccination? MM slash DD slash YYYY Which vaccine did you have?* Pfizer Moderna Johnson & Johnson (Jansen) AstraZeneca Novartis Do you have an increased risk of bleeding?* Yes No Not sure Please provide details regarding your increased risk of bleeding*We need this information in order for our medical provider to determine if it is safe to perform this test. 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. CONSENT AND RELEASE*In consideration of your participation in this COVID-19 Antibody test procedure, you hereby agree to assume all risks of injury or death to yourself. You also understand that your test results are intended to be used for educational purposes only and are not designed to replace the care or advice of a medical provider. If you have a disease condition, fall into certain high-risk categories such as an increased risk for bleeding, you should promptly consult with your physician and obtain his or her approval prior to engaging in this test procedure. Neither Reliant Health Services LLC nor the antibody test manufacturer and/or marketer is liable for any health consequences resulting from your participation in this test procedure, and neither entity or their staff is responsible for ensuring that you have consulted with your physician. Your signature below authorizes Reliant Health Services LLC to seek immediate medical assistance on your behalf if warranted. YOU HEREBY RELEASE RELIANT HEALTH SERVICES LLC AND ALL OF ITS OFFICERS, PERSONNEL AND AGENTS FROM ANY AND ALL DAMAGES AND CLAIMS CAUSED BY OR RESULTING FROM YOUR PARTICIPATION IN THIS TEST PROCEDURE FOR ANY REASON INCLUDING GROSS NEGLIGENCE. This release shall also be binding upon your heirs, executors, and administrators. I AGRRE TO RELEASE RELIANT HEALTH SERVICES LLC AND ALL OF ITS OFFICERS, PERSONNEL AND AGENTS FROM ANY AND ALL DAMAGES AND CLAIMS AS DETAILED.Signature*Unique ID for Verification CommentsThis field is for validation purposes and should be left unchanged.
