COVID-19 Patient Screening Consent Form
- I authorize Amerejuve to collect my blood with a finger stick and a nasopharyngeal swab for COVID-19 screening.
- I acknowledge the test is not certified by the U.S. Food & Drug Administration (FDA).
- I authorize Amerejuve to perform testing on my specimen and communicate the results.
- I understand the processing of the specimen and results may take between 24 to 48 hours.
- Amerejuve will only release the test results to the patient or authorized assigned designee. Test results will be communicated via text/email. I authorize Amerejuve to utilize these communication channels to notify me of my results.
- I am the parent or legal guardian (if the patient is a minor or dependent) of the patient named above
- By selecting checking the box next to “I have read and agree to the Consent Form” field when making an online appointment, I acknowledge that I have read, understand, agree, certify, and/or authorize the information. I further agree to hold harmless Amerejuve, its officers, directors, employees, contractors and agents against all liability, obligations, claims, loss and expense arising out of any liability.
COVID-19 Testing Disclosure Form
In order to be tested, you MUST:
- Have or had symptoms consistent with COVID-19.
- Been exposed to someone with COVID-19
- Have a COVID-19 test prescription from your healthcare provider
- Read and accept the consent form
- Schedule an appointment on our website
Schedule Your Appointment
- I have a prescription for COVID-19 testing-Sign up for an appointment at NorthClarkMG.com. If no appointments are available, check back the next day or call 812-288-2488 to request one.
- I do not have a prescription-Sign up for an appointment at Amerejuve.com. If there are no appointments available, please check back the next day or call Houston, TX: 713-960-6262 / Atlanta, GA: 770-509-0000 to request one.
- If you are a healthcare worker, we would like for you to call our facility to come in and get tested at Houston, TX: 713-960-6262 / Atlanta, GA: 770-509-0000. We will provide special accommodations for healthcare workers.
- This test is not approved by the FDA, only highly complex CLIA certified labs can run this test.
- Negative results do not rule out SARS-CoV-2 infection, particularly in those who have been in contact with the virus. Follow-up testing with a molecular diagnostic should be considered to rule out infection in these individuals.
- Results from antibody testing should not be used as the sole basis to diagnose or exclude SARS-CoV-2 infection or to inform infection status.
- Positive results may be due to past or present infection with non-SARS-CoV-2 coronavirus strains, such as coronavirus HKU1, NL63, OC43, or 229E.
- This antibody test does not identify people plasma donors for treatment of patients suffering from COVID-19 infection.