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COVID Antibody Test - Patient Consent and Waiver

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

Information about POINT-OF-CARE ANTIBODY TEST FOR COVID-19

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 an Antibody Test?

Your body’s immune system creates antibodies after being infected by Covid-19. The Antibody SARS-CoV-2 is a test that looks in your blood for these antibodies. This can be used to determine whether you were previously infected with Covid-19.

The test Ravenclaw Health is using is called the Covid-19 IgG/IgM Rapid Test Device. It is approved by Health Canada. The test is administered by puncturing your finger and obtaining a small blood specimen. A drop of blood will be placed onto the test. Much like a pregnancy test, the result will show on the test cassette after a period of time.

The Test is administered by a licensed health care professional.

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

Potential risks include:

Risk of discomfort at the finger site where blood prick occurs
Risk of fainting for those who cannot stand the sight of blood
Risk of infection
Risky behaviour after a positive test. Antibodies may or may not make you immune to Covid-19 as it is not yet known whether antibodies offer full protection or for how long. Assuming you are protected is a risk that can be mitigated by wearing a mask and following public health guidelines.
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
Peace of mind knowing whether you have had Covid-19
Helping you decide whether to get vaccinated against Covid-19 (please speak to your health care provider about this decision)

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 had Covid-19. It also means you may be protected from getting Covid-19 again.

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

A negative test result means you probably have not had Covid-19. You could also get a negative test result if you currently have Covid-19 (because your body still has to make the antibodies).

INFORMED CONSENT TO POINT-OF-CARE ANTIBODY TEST FOR COVID-19 -

I hereby consent to have the SARS-CoV-2 POC antibody 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 currently asymptomatic.

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 obtaining a drop of my blood from my finger.

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 antibodies. I understand that it is unknown how much protection antibodies provide or for how long, and that I must therefore continue to exercise caution since I could possibly get infected again or infect others.

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 negative test if I am currently infected or was only recently infected. I acknowledge that Ravenclaw Health LP cannot guarantee the accuracy of any test and therefore advises me to continue to wear a mask and physically distance from persons outside my household even if I receive a positive result. I understand some tests could be defective and show an invalid result. I understand that having antibodies 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 material 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. I understand that if I do not have a Test performed, the consequence to me is that I do not know whether I have had the Covid-19 virus.

I understand that the Test that will be provided to me is not a test to determine whether I am currently infected with Covid-19.

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

I understand and acknowledge that Ravenclaw Health LP is unable to prevent or avoid manufacturing defects in any 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 11:35 pm EDT

COVID Antibody Test - Patient Consent and Waiver Uploaded by Ravenclaw Health - reception@ravenclawhealth.com IP 142.126.183.227