Global Diagnostic Labs, LLC
PATIENT CONSENT FOR ANTIGEN AND RT-PCR COVID-19 TEST
Name: _________________________________________________ Date of Birth: ____/____/______
Home Address: _______________________________________________________________________________
INSURANCE INFORMATION (OMIT IF CASH PAY)
INSURANCE PROVIDER: ________________________________________________________________
MEMBER ID: _______________________________________________________________________
GROUP NUMBER: _________________________________________________________
INSURED NAME and DATE OF BIRTH: __________________________________________________
RELATIONSHIP TO INSURED: ________________________________________________________________
I authorize Global Diagnostic Labs, LLC (“Global”) to collect a saliva sample from me and conduct RT-PCR
COVID-19 testing of the collected sample. I understand that RT-PCR COVID-19 and Antigen testing services by Global
are in accordance with the Federal COVID-19 Pandemic Emergency Declaration.
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I acknowledge and understand that there are risks and benefits associated with undergoing a RT-PCR
COVID-19 test, and there is the potential for false positive or false negative test results. The RT-PCR COVID 19 test
being administered does not provide a medical diagnosis of COVID-19 or any other disease. The test result provides
information for my healthcare provider to assist in determining whether I should receive further testing or medical
treatment. Further, I understand that the RT-PCR COVID-19 tests administered by Global have not been cleared or
approved by the U.S. Food and Drug Administration (“FDA”), but have been authorized under an emergency use
authorization granted by the FDA. I assume complete and full responsibility to take appropriate action with regards to my
test results. Should I have any questions or concerns regarding my results, I shall promptly seek advice and treatment
from a medical provider.
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I understand that I have a right to confidential treatment of my test sample and test results. I understand that I
will receive the test results from Global. I authorize representatives of Global to review my test results and to disclose such
test results to county, state, or any other governmental entity as may be required by law.
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I understand that Global will have access to my sample(s) and that my sample(s) will be used only for the purposes for which I have given my consent or as allowed under applicable law. I understand samples will be discarded within 48 hours of testing. If a specimen is used for research and development, the specimens are not individually identifiable, i.e., the subject's identity is not known and can not be ascertained by the research team or any other individuals associated with the research.
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I understand and acknowledge that Global and its affiliates, representatives and agents are administering RT-
PCR COVID-19 testing services only and are not providing any medical or other healthcare services. I authorize Global to
communicate with other medical providers regarding my treatment and care as it relates to RT-PCR COVID-19 testing
services. I may seek such healthcare services beyond those addressed in this consent from a healthcare provider of my
own choosing.
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I authorize Global to bill my insurance provider for the RT-PCR COVID-19 testing services performed by
Global. I understand that I am financially responsible for the services rendered by Global.
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I authorize Global to use the information contained herein to contact me for matters related to healthcare
treatment, including eligibility for free testing kits provided by the federal government.
I hereby affirm that I have read and understand this document, had the opportunity to ask questions and
consult with a medical provider of my choosing, had the opportunity to seek additional medical opinions, and
received satisfactory answers to all of my questions.
I hereby affirm that all information I provided herein is true and accurate.
I understand and accept all risks contained in this document and give my informed consent voluntarily to
receive a RT-PCR COVID-19 Test from Global. If applicable, I authorize Global to bill my health insurance
provider for the services rendered consistent with this consent.
Patient Name: _________________________ Signature: ___________________________ Date: ___ / ___ / _____
INFINITY WELLNESS SOLUTIONS, LLC
PATIENT CONSENT FOR NEW AND/OR ESTABLISHED PATIENT E&M OFFICE VISIT (INTERACTIVE AUDIO/VIDEO)
Name: _________________________________________________ Date of Birth: ____/____/______
Home Address: _______________________________________________________________________________
INSURANCE INFORMATION (OMIT IF CASH PAY)
INSURANCE PROVIDER: ________________________________________________________________
MEMBER ID: _______________________________________________________________________
GROUP NUMBER: _________________________________________________________
INSURED NAME and DATE OF BIRTH: __________________________________________________
RELATIONSHIP TO INSURED: ________________________________________________________________
I authorize INFINITY WELLNESS SOLUTIONS, LLC to NEW AND/OR ESTABLISHED PATIENT E&M
OFFICE VISIT (INTERACTIVE AUDIO/VIDEO).
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I acknowledge and understand that there are risks and benefits associated with NEW AND/OR
ESTABLISHED PATIENT E&M OFFICE VISIT (INTERACTIVE AUDIO/VIDEO). I assume complete and full
responsibility to take appropriate action with the results of NEW AND/OR ESTABLISHED PATIENT E&M OFFICE
VISIT (INTERACTIVE AUDIO/VIDEO). Should I have any questions or concerns regarding my results, I shall promptly
seek advice and treatment from a medical provider.
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I understand that I have a right to confidential treatment. I understand that I will receive NEW AND/OR
ESTABLISHED PATIENT E&M OFFICE VISIT (INTERACTIVE AUDIO/VIDEO) from INFINITY WELLNESS
SOLUTIONS, LLC. I authorize representatives of INFINITY WELLNESS SOLUTIONS, LLC to review my results and
to disclose such results to county, state, or any other governmental entity as may be required by law.
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I understand that INFINITY WELLNESS SOLUTIONS, LLC will have access to my results and that my
results will be used only for the purposes for which I have given my consent or as allowed under applicable law.
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I understand and acknowledge that INFINITY WELLNESS SOLUTIONS, LLC and its affiliates,
representatives and agents are administering NEW AND/OR ESTABLISHED PATIENT E&M OFFICE VISIT
(INTERACTIVE AUDIO/VIDEO) only and are not providing any other medical or healthcare services. I understand that I
must seek such healthcare services from a healthcare provider of my own choosing.
I hereby affirm that I have read and understand this document, had the opportunity to ask questions and
consult with a medical provider of my choosing, had the opportunity to seek additional medical opinions, and
received satisfactory answers to all of my questions.
I hereby affirm that all information I provided herein is true and accurate.
I understand and accept all risks contained in this document and give my informed consent voluntarily to
receive NEW AND/OR ESTABLISHED PATIENT E&M OFFICE VISIT (INTERACTIVE AUDIO/VIDEO)
from E&M OFFICE VISIT (INTERACTIVE AUDIO/VIDEO). If applicable, I authorize NEW AND/OR
ESTABLISHED PATIENT E&M OFFICE VISIT (INTERACTIVE AUDIO/VIDEO) to bill my health
insurance provider for the services rendered consistent with this consent.
Patient Name: _________________________ Signature: ___________________________ Date: ___ / ___ / _____
Global Diagnostic Labs, LLC
PATIENT CONSENT FOR INFLUENZA A & B TEST
Name: _________________________________________________ Date of Birth: ____/____/______
Home Address: _______________________________________________________________________________
INSURANCE INFORMATION (OMIT IF CASH PAY)
INSURANCE PROVIDER: ________________________________________________________________
MEMBER ID: _______________________________________________________________________
GROUP NUMBER: _________________________________________________________
INSURED NAME and DATE OF BIRTH: __________________________________________________
RELATIONSHIP TO INSURED: ________________________________________________________________
I authorize Global Diagnostic Labs, LLC ("Global") to collect a saliva sample from me and conduct Influenza A & B testing of the collected sample.
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I understand that I have a right to confidential treatment of my test sample and test results. I understand that I will receive the test results from Global. I authorize representatives of Global to review my test results and to disclose such test results to the county, state, or any other governmental entity as may be required by law.
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I understand that Global will have access to my sample(s) and that my sample(s) will be used only for the purposes for which I have given my consent or as allowed under applicable law. I understand samples will be discarded within 48 hours of testing. If a specimen is used for research and development, the specimens are not individually identifiable, i.e., the subject`s identity is not known and can not be ascertained by the research team or any other individuals associated with the research.
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I understand and acknowledge that Global and its affiliates, representatives, and agents are administering Influenza A & B testing services only and are not providing any medical or other healthcare services. I authorize Global to communicate with other medical providers regarding my treatment and care as it relates to Influenza A & B testing services. I may seek such healthcare services beyond those addressed in this consent from a healthcare provider of my own choosing.
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I authorize Global to bill my insurance provider for the Influenza A & B testing services performed by Global.
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I understand that I am financially responsible for the services rendered by Global.
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I authorize Global to use the information contained herein to contact me for matters related to healthcare treatment, including eligibility for free testing kits provided by the federal.
I hereby affirm that I have read and understood this document, had the opportunity to ask questions and consult with a medical provider of my choosing, had the opportunity to seek additional medical opinions, and received satisfactory answers to all of my questions.
I hereby affirm that all information I provided herein is true and accurate.
I understand and accept all risks contained in this document and give my informed consent voluntarily to receive an Influenza A & B Test from Global. If applicable, I authorize Global to bill my health insurance provider for the services rendered consistent with this consent.
Patient Name: _________________________ Signature: ___________________________ Date: ___ / ___ / _____