COVID 19 Consent

Phamatech COVID-19 IgG/IgM Rapid Test:


Name:                                                                                                   DOB:

Occupation:                                                                            Mobile Phone:

Previously diagnosed with COVID-19. Yes / No

Previous exposure to other individuals diagnosed as COVID-19 positive. Yes / No

Previous recent cold or flu-like symptoms (in 2020). Yes / No - If YES, when?

The patient reports that they do not have a fever.

The patient reports that they do not have a new or worsening cough or shortness of breath.

The patient reports that they do not have any cold or flu-like symptoms.

The patient reports that they do not have any change of smell or taste.

The patient reports that they do not have any new onset of diarrhea.

During your visit you are tested for COVID-19 antibodies/seropositivity. Results from this SARS-CoV-2 IgG/IgM Rapid Test should not be used as the sole basis for diagnosis. At this time, it is unknown for how long IgM or IgG antibodies may persist following infection and if seropositive state can prevent and protect you from recurrent COVID-19 re-infection if exposed to COVID -19 positive individuals.

Our Medical Office does not provide clinical observation and/or diagnostic (nasal-throat swab) testing. After Testing with Phamatech COVID-19 IgG/IgM Rapid Test today you are solely responsible to follow up with your health care provider or any type of medical facility for any clinical determination, additional testing and treatment if required.

You should continue home quarantine, social distancing, interventions to decreased spread of disease, as instructed by your County/State or Federal administration. The patient has been told, if there are any new symptoms please contact their Primary Care Provider or call 911 if medical emergency.

IMPORTANT NOTE!!! The test you had today is a first step for diagnosis of past coronavirus infection including asymptomatic coronavirus infection. In case you are tested positive - You are STRONGLY advised to seek a follow-up treatment or additional diagnostic testing offered by your regular medical provider (MD or NP). Such care may be important for your health safety.

The results will be reviewed by our medical staff and we will contact you with the results of your coronavirus test in 1-2 hours. Patient acknowledged understanding of instructions as stated.

Signature/Printed Name                                                                                                 Date