On-Site Testing form - Complete ON DAY OF TEST not before

Complete before COVID, Flu, Strep, Cholesterol or Glucose testing

Please correct the errors described below.

Testing sites must report data for all diagnostic and screening testing completed, which includes molecular, antigen, and antibody testing, for each individual tested. These data must be reported daily, within 24 hours of test completion, to the appropriate local, state , territorial or tribal health department, based on the individual’s residence.

Patient is Ineligible for Strep test if: - They are younger than 3yr age, - Pregnant, - Immunocompromised. Please contact your primary care physician for further assistance.

Patient is ineligible for Flu/Strep tests and should be referred to primary care physician or emergency department If patient has:

Fever>103 F, Pulse >100 beats/min, Systolic Blood Pressure <100mgHg

Patient should be assessed further by pharmacist/healthcare professional if they present with:

Fever>100.4, Sore throat, Nausea/Vomiting/Abdominal pain, Headache

Based on pharmacist assessment, a Strep test may or may not be administered.

Patient would be Ineligible for Flu test if (1) they are younger than 13 years (2) Pregnant (3) Immunocompromised (4) Symptoms consistent with influenza for >48hrs. Please contact your primary care physician or visit an emergency department.

I hereby grant permission to Hillcrest Pharmacy & Compounding (HPC) to perform certain screening tests as set forth below at my direction, which may include obtaining specimens of mucus by nasal, nasopharangeal or oropharangeal swab or blood by venipuncture or finger stick. I authorize HPC to obtain these screening results and provide them to me via phone, email or mail. I agree to pay for the tests in full at the time of service. I understand that the testing has not been ordered by a physician and is being done for my own use and not for medical diagnostic or treatment purposes. Because the tests are not ordered by a physician, insurance coverage may not be available, including Medicare or Medicaid. Upon your request, HPC or it’s affiliates may submit the tests to any insurance company for reimbursement. However if insurance does not reimburse due to any reason, I understand that I will be responsible for the Usual & Customary charge for these tests. I further understand that the test results will not be forwarded to any medical professional for diagnosis of any medical condition. It is my responsibility to share the test results with my physician at my sole option. I, alone, am responsible for obtaining medical information, treatment or services from a doctor or other health care provider in relation to test results.

I authorize HPC to report the administration of this test to the state per regulations. I understand the state may use my information and contact me for any purpose deemed necessary.

I understand these tests have not been cleared or approved by the FDA and all these tests have been authorized by FDA under EUA’s for use by authorized laboratories.

I have been provided with, read and understood the patient handouts or factsheets for these tests. I understand the risks, limitations, nature of these tests.

I hereby and for my heirs, executors, administrators, successors and assigns release, acquit and forever discharge HPC, its subsidiaries and affiliates, and each of their agents, employees, officers, directors, servants, successors, heirs, executors, and administrators, (collectively, "HPC"), of and from any and all claims, actions, causes of action, demands, rights, damages, injuries and property damage and the consequences thereof resulting or to result from the testing. I acknowledge that I have read this release form prior to signing it and that I understand its contents. I understand and agree that I will not be able to sue HPC for any injury or property damage I may suffer as a result of the testing. I HEREBY CERTIFY THAT I HAVE READ THE ABOVE ACKNOWLEDGEMENT AND HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENTS. BY SIGNING BELOW, I CONSENT TO UNDERGO THE SELF-DIRECTED LABORATORY TESTING UNDER THE CONDITIONS SET FORTH HEREIN.

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