COVID-19 Screening Consent Form and Waiver
This consent provides Roswell Pain Specialists, LLC with your permission to perform a COVID-19 screening procedure based on Roswell Pain Specialists need to maintain a safe environment for employees, contractors, vendors, and other essential persons with whom you may come in contact. By signing below, you are indicating that you voluntarily consent to this procedure for the detection of COVID-19.
The test being administered involves a nose swab to obtain a sample of nasal secretion which will then be tested within 2-3 days or more for the presence of the antibodies that may indicate the presence of COVID-19.
This test has been allowed for the use by the Food and Drug Administration (“FDA”) but has not been approved by the FDA. This test alone may not be sufficient to detector rule out the possibility that you have been exposed to or are infected with COVID-19. You should carefully monitor your own symptoms, and notwithstanding the results of any testing, you must stay home and consult with your physician if you experience symptoms of COVID-19.
You have the right to discuss the proposed testing with your physician, to learn about the purpose, potential risks, and benefits of any testing. Based upon your test results, if you are denied entry into Roswell Pain Specialists, you should contact a physician or other medical professional advice. Because of the ongoing public-health crisis, it may be necessary for Roswell Pain Specialists to share the results of your test with the public health authorities. By signing below, you consent to the disclosure of such information as requested, recommended, or required by federal, state, and local public health authorities.
By signing below, you agree to release and waive any claim arising from your selection to receive this voluntary screening, that may arise against Roswell Pain Specialist and its designated medical providers and staff members. In addition, by signing below, you acknowledge that any testing that may be performed for COVID-19 has not been approved by the Food and Drug Administration (FDA). Accordingly, you agree to release and waive any claim that might arise against Roswell Pain Specialists and its designated medical providers and staff member for any risk, side effects, or complications resulting from the testing.