COVID Testing—English - Soft Cell Labs

Click on ALL statements below to indicate your consent and agreement for this test.

I attest that to the best of my knowledge and belief, all data provided in this form will be accurate and complete.

Yes

I understand and agree to the following: All healthcare services come with some risk: One of the risks associated with this screening service is that my screening may fail to accurately and correctly assess my current health status. No promise has been made to me concerning a result, outcome, or cure: I should contact my healthcare provider as soon as possible if my symptoms worsen: I consent to receive healthcare screening services provided by Soft Cell Laboratories.

Yes

By using this screening tool, I consent to being contacted by Soft Cell Laboratories via phone, text, email, and mail.

Yes

I have read the informed consent and I give permission to Soft Cell Laboratories to perform laboratory testing as described. I understand and agree that my leftover specimen and clinical information may be used, without information directly identifying me, for research, education, and other business purposes of Soft Cell Laboratories (each a "secondary use" and together "secondary uses"). I understand that this may involve Soft Cell Laboratories sharing my leftover specimen and clinical information with other third parties. My leftover specimen and clinical information will be assigned a unique code before any secondary uses. My name or other personal identifying information will not be used in or linked to my specimen and clinical information when they are shared with third parties unless I specifically authorize that disclosure. I understand that Soft Cell Laboratories, itself or through its contractors on its behalf, may contact me at a later date regarding my interest in participating in other research activities, including contributing additional clinical information or specimens for use in such activities and/or authorizing the use of my identifiable information for secondary uses.

Yes

The information you provide us used to record and contact you with testing information. Your mobile phone, email address.

Personal Information:

Legal First Name

Legal Middle Name

Legal Last Name

Date of Birth:

Month

Day

Year

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Confirm Email

Phone/Mobile (xxx-xxx-xxxx)

SARS-CoV-2 RT-PCR-COVID-19 TESTING