Pop-up site Consent Forms

Authorization and Consent for COVID-19 Diagnostic Testing: I voluntarily consent and authorize the City of Cincinnati Health Department, hereafter referred to as the "CHD" to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test. I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample by my healthcare provider through a nasopharyngeal swab, oral swab, or other recommended collection procedures according to the manufacturer's stated directions. I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and there may be a potential for false positive or false negative test results. I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.

I understand I will receive the Cincinnati Health Department Post-Test Procedures and be offered the Cincinnati Health Department's Notice of Privacy Practices prior to my child receiving a COVID-19 diagnostic test.

Release of testing results: I acknowledge that my COVID-19 test results and associated information may be released or obtained by CHD for treatment or continuity of care, and by the City Health Director to release to persons or entities to control, prevent, or mitigate the spread of COVID-19.

Disclosure to Government Authorities: I acknowledge and agree that my test results and associated information may be shared with appropriate county, state, or other governmental and regulatory entities as may be permitted by law.

Release: To the fullest extent permitted by law, I hereby release, discharge and hold harmless, CHD, including, without limitation, any its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results.
I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I have been informed about the purpose of the COVID-19 diagnostic test, procedures to be performed, potential risks and benefits, and associated costs. I have been provided an opportunity to ask questions before proceeding with a COVID-19 diagnostic test and I understand that if I do not wish to continue with the collection, testing, or analysis of a COVID-19 diagnostic test, I may decline to receive continued services. I have read the contents of this form in its entirety and voluntarily consent to undergo diagnostic testing for COVID-19.