RT-PCR SALIVA COLLECTION KIT REGISTRATION Register RT-PCR Test Kit Submission Form Form that patients enter their data into DO NOT REGISTER YOUR KIT UNTIL YOU ARE READY TO COLLECT THE SALIVA SPECIMEN. To begin your kit registration please start by completing the form below and follow the simple instructions. Have you eaten, drink anything, chewed gum or smoke in the last thirty (30) minutes?* Yes No Please be aware that all persons are asked to avoid drinking water for at least 20 minutes and not to eat or drink anything else, smoke, brush your teeth or chew gum for about 30 minutes before collecting your saliva specimen. That way, the samples are as clean and contaminant-free as possible.That is perfect. Please click the Next button below to continue. Name of the person taking this test.*IMPORTANT: THE SPELLING OF YOUR NAME MUST MATCH YOUR GOVERNMENT ISSUED ID EXACTLY. Note: Please be sure to match the collection kit serial # with the person you enter in the next steps. (if there are multiple persons in your household being tested) First Last Is this person a minor (child)?*We need this information to be able to securely deliver test results under the guardian's profile / email address. Yes No Your Name (Parent / Legal Guardian)* First Last 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).Would you like to send the test result to a digital wallet? Yes, send test result to Bindle Bindle is a secure wallet for your health records and an easy way to privately share your COVID health status with others. (IMPORTANT: You must use the same email address used on Bindle for this registration. A Bindle account is not needed prior to completing this registration. ) Learn more about Bindle.Email Address of person taking this test*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 Date of Birth of person taking this test* MM slash DD slash YYYY Government Issued ID Number*Note: If this is a minor child without a govenrment issued ID enter the number "0" Type of ID* Passport Drivers License Military ID NEXUS, SENTRI or FAST Other TSA Compliant ID Minor child without ID 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. BE SURE THIS SERIAL NUMBER IS MATCHED TO THE PERSON JUST ENTERED ON THE LAST PAGEEnter the Barcode ID / Serial Number (located on the tube as pictured above)*(Begins with FR) Re-Enter the Barcode ID / Serial Number*(Begins with FR) Is this test for travel to Hawaii?* Yes No Is this test for travel to any other destination that requires the test performed with "Medical Administration or Supervision"?*If you have any doubt regarding the requirements for your destination, select Yes. Yes No IMPORTANT! IF YOU ARE TRAVELING TO HAWAII, COLLECTION OF YOUR SPECIMEN MUST BE SUPERVISED OVER VIDEO. FURTHER INSTRUCTIONS WILL BE PROVIDED TO COMPLETE THIS PROCESS.IMPORTANT! IF YOU ARE TRAVELING TO A DESTINATION WITH MEDICAL ADMINISTRATION REQUIREMENTS, THIS IS SATISFIED BY THE COLLECTION OF YOUR SPECIMEN BEING SUPERVISED OVER VIDEO. FURTHER INSTRUCTIONS WILL BE PROVIDED TO COMPLETE THIS PROCESS AT THE END OF THIS REGISTRATION. 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/.Signature* Subscribe to our Newsletter to stay up to date on the latest COVID-19 testing and safety protocols.You are almost finished registering your kit! Click the Submit button below to submit your registration and then follow the instructions on the next page for the collection of your saliva specimen. One last question...HiddenDate YYYY dash MM dash DD CommentsThis field is for validation purposes and should be left unchanged.
