Consent Form for Voluntary COVID-19 Testing

Required

Consent Form for Voluntary COVID-19 Testing - Student

Your child’s school is now offering a voluntary K-12 COVID-19 screening program for students and school-based staff. This program uses Mako Medical Laboratories (“Mako”) as their testing partner.  Your child’s school will only administer this voluntary test with parent consent for minor students.  Adult students may provide direct consent.  If you wish to take the test, please complete this form.   

Parent/Guardian Information
 
You will be notified with test results either via cell phone or email, or both.
Parent/Guardian or Adult Student Name:required
First Name
Last Name
Results will be texted to this cell #
Child/Student Information
Child/Student Name:required
First Name
Last Name
(Must contain a date in M/D/YYYY format)
Race/Ethnicity:required
Gender:required
Consent

By typing my first and last name below, I attest that: 

A.     I authorize my child’s school to conduct specimen collection and testing of my child or me (if student age 18 or older) for COVID-19 by nasal swab. 

B.     I acknowledge that a positive test result is an indication that my child or I (if student age 18 or older) may have the COVID-19 virus and he/she or I must follow the school’s protocol for positive results. 

C.     I understand that the school is not acting as my or my child’s medical provider; that this testing does not replace treatment by my or my child‘s medical provider; and I assume complete and full responsibility to take appropriate action concerning my or my child’s test results. I agree to seek medical advice, care, and treatment from my or my child’s medical provider if I have questions or concerns, or if my or his/her condition worsen. 

D.    I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. 

E.     I have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent from my child’s school. I understand that Mako is not responsible for providing the school’s program information. I have been given the opportunity to ask questions before I sign, and I may ask additional questions at any time.  

F.     My consent for this screening test for COVID-19 is knowing and voluntary. 

Please type your full first and last name in the box above to confirm your e-signature.
Must contain a date in M/D/YYYY format