Darling's Home Care
COVID-19 Rapid Antigen Consent Form

First Name

Last Name

Email Address

Date of Birth

Phone

Gender

Street Address

City

Region/State/Province

Postal / Zip code

Race

Ethnicity

Primary Care Physician

Employer

Have you traveled outside the state of Pennsylvania in the last 14 days *

Yes

Have you been in direct contact with someone who is confirmed to have COVID19? *

Yes

Have you tested for COVID19 in the last 30 days? *

Yes

Check all symptoms you have experienced that might be associated with COVID-19.

None

Fever of 100 or greater

New Onset Cough

Shortness of Breath

Sore Throat

New Onset Congestion or Runny Rose

New Onset Headache

New Onset Diarrhea

New Onset Nausea or Vomiting

New Onset Fatigue

New Onset Muscle Aches

Recent loss of taste or smell

When did symptoms first appear?

Please carefully read and sign the following Informed Consent:

I, the undersigned, have been informed about the test purpose; procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.

(814) 726-0591

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Darling's Home Care COVID-19 Rapid Antigen Consent Form

Darling's Home Care
COVID-19 Rapid Antigen Consent Form