VOLUNTARY CONSENT TO RECEIVE COVID-19 TESTS AND WAIVER AND RELEASE OF LIABILITY AND HOLD HARMLESS AGREEMENT

People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. Older adults and people who have severe underlying medical conditions like heart or lung disease or diabetes seem to be at higher risk for developing more serious complications from COVID-19 illness. Symptoms may appear within 2-14 days after exposure to the virus. People with these symptoms may have COVID-19; fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting an, diarrhea. These are just some of the symptoms of COVID-19 and they are not intended to be an exhaustive list. If you have any one or more of these symptoms, or other symptoms, and you believe or are concerned you might have contracted COVID-19, or you have had close contact (within 6 feet for a total of 15 minutes or more) with someone with confirmed COVID-19, or you have taken part in activities that put you at higher risk for COVID-19 because you cannot socially distance as needed, such as travel, attending large social or mass gatherings, or being in crowded indoor settings, or you have been asked or referred to get testing by their healthcare provider, or state or local health department, you may decide you want to get tested for COVID-19. If you do get tested, self-quarantine/isolate at home pending test results and follow the advice of your health care provider or a public health professional. If you test positive, know what protective steps to take to prevent others from getting sick, such as the following.ad

  • Stay home. Most people with COVID-19 have mild illness and can recover at home without medical care. Do not leave your home, except to get medical care. Do not visitpublic areas.
  • Take care of yourself. Get rest and stay hydrated. Take over-the-counter medicines, such as acetaminophen, to help you feel better.
  • Stay in touch with your doctor. Call before you get medical care. Be sure to get care if you have trouble breathing, or have any other emergency warning signs, or if you think it is an emergency.
  • Avoid public transportation, ride-sharing, or taxis.
  • Separate yourself from other people
  • As much as possible, stay in a specific room and away from other people and pets in your home. If possible, you should use a separate bathroom. If you need to be around other people or animals in or outside of the home, wear a mask
  • Tell your close contacts that they may have been exposed to COVID-19. An infected  person can spread COVID-19 starting 48 hours (or 2 days) before the person has any symptoms or tests positive. By letting your close contacts know they may have been exposed to COVID-19, you are helping to protect everyone. Additional guidance is available for those living in close quarters and shared housing.
  • If you are diagnosed with COVID-19, someone from the health department may call you. Answer the call to slow the spread.
  • If you test negative, you probably were not infected at the time your sample was collected.  The test result only means that you did not have COVID-19 at the time of testing. Continue to take steps to protect yourself.

 

  1. I have read the above, and I understand that potential symptoms of getting COVID-19, and  the need to take appropriate action to get tested if I have any of the symptoms indicated above, or any other symptom that I believe may be COVID-19 related, and some of those may be dangerous and could expose me to the risk of bodily injuries, illness, disability, economic or emotional loss or even death. I understand that these potential risks may also include other risks that are unknown at this time or are otherwise not reasonably foreseeable. Having read and considered the above, I KNOWINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE NEGLIGENCE OF RELEASEES, and assume full responsibility for my participation in receiving a COVID-19 test.
  2. In signing this form, I give permission for me or my child to be tested for COVID- 19 and  understand the risks and benefits of getting the COVID-19 test and provide informed consent to Sure Medical Care to receive the COVID-19 test result.
  3. In consideration for receiving the COVID-19 test, I hereby RELEASE, WAIVE,  DISCHARGE, HOLD HARMLESS AND COVENANT NOT TO SUE SURE MEDICAL CARE Inc, officers, employees and volunteers (hereinafter referred toas RELEASEES) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, injury, or illness including, without limitation, any loss, damage, injury, or illness caused by or related to receiving the COVID-19 test, that may be sustained byme or other family members or any person who may contract COVID- 19 from the undersigned or such participating individuals or from any property belonging to Sure Medical Care, Inc. WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise, in any way connected to or arising out of the receiving the COVID-19 test.
  4. The undersigned does for him/herself, his/her heirs, executors, administrators and assigns  hereby release, waive discharge and relinquish any claims or actions or causes of action, aforesaid, which may hereafter arise for him/herself and forhis/her estate, and agrees that under no circumstances will he/she or his/her heirs, executors, administrators and assigns prosecute, present any claim for personal injury, bodily injury, property damage or wrongful death against Sure Medical Care, or any of its officers, agents, servants, volunteers or employees for any of said causes of action.
  5. I UNDERSTAND THAT SURE MEDICAL CARE WILL NOT BE RESPONSIBLE FOR  ANY MEDICAL COSTS OR DAMAGES ASSOCIATED WITH ANY INJURY OR  ILLNESS IN ANY WAY RESULTING FROM THE COVID-19 TEST.

  6. IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have  read the Voluntary Consent to Receive a COVID-19 test and Waiver and Release of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent or ifunder the age of 18 my Parent/Guardian consents; I have no questions regarding the scope  or intent of this Agreement, but if I do, I am and have been fully advised that I or my Parent/Guardian may seek legal counsel or consult with others. I execute this Release for full, adequate and complete consideration fully intending to be bound by same and understand the legal consequences of signing this Agreement.

     

  7. By indicating my consent below, I authorize Sure Medical Care to disclose my child’s protected health information described below to the persons or entities identified in this form.

        I hereby authorize the release of the following protected health information:

    • My or my child’s name; and
    • The result of my or my child’s COVID-19 (novel coronavirus test)

        This information may be released to:

    • My child’s Unified School District
    • Me, as the child’s legal personal representative

        This information will be used for:

    • Addressing the health and safety of our students through medical surveillance of COVID-19 cases at our schools.

         I also understand and agree to the following:

    • Any information used or disclosed through this authorization may no longer be protected by privacy laws and may be subject to re-disclosure by the person or organization receiving it.