COVID Antigen Test - Patient Consent and Waiver

Thank you! Please review and sign this form to complete your booking.

INFORMATION ABOUT POINT-OF-CARE RAPID COVID-19 DIAGNOSTIC TESTING

What is COVID-19?

COVID-19 is caused by the SARS-CoV-2 virus. The virus, which can cause mild to severe respiratory illness, has spread globally. Symptoms include cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat or new loss of taste or smell.

What is the COVID-19 ANTIGEN RAPID TEST DEVICE ?

The Assure Tech Covid-19 Antigen rapid test is a type of test called an antigen test. Antigen tests are designed to detect proteins from the virus that causes COVID-19 in respiratory specimens, for example nasal swabs.

What are the known and potential risks and benefits of the test?

Potential risks include:

Possible discomfort or other complications that can happen during sample collection.
Possible incorrect test result (see below for more information).

Potential benefits include:

The results, along with other information, can help you make informed decisions about your health.
The results of this test may help limit the spread of COVID-19 to your family and others in your community.

What does it mean if I have a positive test result?

If you have a positive test result, it is very likely that you have COVID-19. Therefore, it is also likely that you may be placed in isolation to avoid spreading the virus to others. There is a very small chance that this test can give a positive result that is wrong (a false positive result). Your local public health unit and/or your healthcare provider will work with you to determine how best to care for you based on your test result(s) along with your medical history, and your symptoms. What does it mean if I have a negative test result?

A negative test result means that proteins from the virus that causes COVID-19 were not found in your sample. It is possible for this test to give a negative result that is incorrect (false negative) in some people with COVID19. This means that you could possibly still have COVID19 even though the test is negative.

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INFORMED CONSENT TO POINT-OF-CARE RAPID COVID-19 DIAGNOSTIC TESTING

I hereby consent to have the SARS-CoV-2 POC antigen test (the “Test”) performed on me by a registered nurse or registered practical nurse who is licensed in the province of Ontario.

I confirm that I have not been found incapable of making my own health care decisions.

I confirm that I am asymptomatic and that, to the best of my knowledge, I have not been previously infected with Covid-19.

I understand that the Test is not funded by the Ontario Health Insurance Plan (“OHIP”) and is being performed outside the public health care system. I understand that this means I must pay a fee to have the Test administered.

I understand that the Test will be administered by taking a sample using a nasal swab.

I understand that the purpose and benefit of the Test is to provide me with a positive or negative result indicating whether I have the Covid-19 virus. I understand and agree that if I test positive for Covid-19, I should contact my local public health unit and it may be recommended that I have an additional test performed using a different type of test that will be confirmed in a

laboratory. I acknowledge that a positive Covid-19 test means that I must follow the directions of Public Health Ontario and my local public health unit, which may include a requirement to selfisolate at home for fourteen (14) days.

I understand that there is the potential for a false positive or false negative result. I also understand that it is possible to have a positive test while I am asymptomatic and that this may mean I am currently infected or that I was recently infected. I acknowledge that Ravenclaw Health LP cannot guarantee the accuracy of any Covid-19 test and therefore advises me to continue to wear a mask and physically distance from persons outside my household even if I receive a negative result. I understand that testing is not considered to be an effective preventative measure for Covid-19 and does not replace public health strategies such as symptom screening, physical distancing, and hand hygiene.

I understand that if I receive a negative test result, I could contract the Covid-19 virus. For this reason, I acknowledge that it is recommended that I continue to take all precautions as I could subsequently become ill and/or infect others.

I understand that the materials risks of the Test are discomfort during sample collection and a false positive or negative result.

I give this Consent voluntarily and confirm that I am not under any duress or pressure to have the Test administered. I understand that there are alternative courses of action, such as not having the Test performed or having a molecular test performed instead of an antigen test. I understand that if I do not have a Test performed, the consequence to me is that I do not know whether I currently have the Covid-19 virus.

I understand that the Test that will be provided to me is not an antibody test that will inform me whether I had Covid-19 in the past.

I confirm that I have had the opportunity to have all of my questions about the Test answered to my full and complete satisfaction.

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I understand and acknowledge that Ravenclaw Health LP is unable to prevent or avoid manufacturing defects in any COVID-19 detection equipment or testing. I hereby waive and release Ravenclaw Health LP from any and all claims for injuries, losses (financial or otherwise) or damages arising from or relating to the Test, whether direct or indirect, howsoever caused.

I authorize my Test results to be disclosed to the local public health unit and any other governmental entity as permitted or required by law.

I understand that Ravenclaw Health LP is not my medical provider and that the Test does not replace medical advice, diagnosis, or treatment by my physician.

I understand that I will be required to present identification at the scheduled appointment.

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April 29, 2021 11:18 pm EDT

COVID Antigen Test - Patient Consent and Waiver Uploaded by Phil Hudson - phil@ccomp.ca IP 184.145.65.64