Intake Form

First Name

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Is This Your First Covid Test?

Are You A Healthcare Employee?

Are You Experiencing Any COVID Symptoms?

When Did These Symptoms Begin?

HIPAA Email Consent

HIPAA Email Consent
VERY IMPORTANT! PLEASE READ!
∙HIPAA stands for the Health Insurance Portability and Accountability Act

∙HIPAA was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information

∙Information stored on our computers is encrypted

∙Most popular email services (ex. Hotmail®, Gmail®, Yahoo®) do not utilize encrypted email

∙When we send you an email, or you send us an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet. In addition, once the email is received by you, someone may be able to access your email account and read it.

∙Email is a very popular and convenient way to communicate for a lot of people, so the federal government has provided guidance on email and HIPAA. See https://www.hhs.gov/hipaa/for-professionals/faq/570/does-hipaa-permit-health-care-providers-to-use-email-to-discuss-health-issues-with-patients/index.html

∙The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email

I understand the risks of unencrypted email and do hereby give permission to the Brighton Eggert Pharmacy to send my COVID test results via unencrypted email

I do not want my results to be sent to me via email.

CORONAVIRUS TESTING CONSENT

 I authorize Brighton Eggert Pharmacy to conduct collection and testing for COVID-19 through a nasalpharyngeal swab. Based on my results, additional testing may be needed for confirmation. 

I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law. I understand that I am not creating a patient relationship with Brighton Eggert Pharmacy by participating in testing. I understand that Brighton Eggert Pharmacy is not acting as my medical provider. I assume complete and full responsibility to take appropriate action with regards to my test results. 

 I understand that the antigen test will produce one of two results; a positive test result indicates that antigens for SARS-CoV-2 were detected, and I am infected with the virus and presumed to be contagious. A negative test result means that antigens from SARS-CoV-2 were not present in the specimen above the limit of detection. However, a negative result does not rule out COVID-19 and should be treated as presumptive and confirmed with a molecular assay, if necessary for patient management. I also understand that, as with any medical test, there is the potential for false positive or false negative test results. 
 
 I have been informed about the test purpose, procedures, possible benefits and risks. I have been given the opportunity to ask questions before I sign. I acknowledge that I have read, understand, agree, certify and/or authorize the information above and further agree to hold harmless Brighton Eggert Pharmacy, including its employees, agents, and contractors from any and all liability and claims.

I agree to the above "Coronavirus Testing Consent"

I certify that, to the best of my knowledge and belief, the information provided here is true and correct.

Please sign below

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Brighton Eggert Pharmacy

Rapid Test Form

Date of Birth

HIPAA Email Consent

CORONAVIRUS TESTING CONSENT

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