Patient Details Form and Covid Consent

Personal Details

Address

Emergency Contact Or Next Of Kin

(Please provide details of who we should contact should you require assistance)

CONSENT

I understand that I can refuse to tick the following:

SIGNATURE:

Consent Form For Coronavirus PCR Testing:

Please read this form carefully and make sure you understand it completely before signing it. If you have any questions, please ask your doctor before signing it.
Please tick every paragraph to confirm that you have read it and sign this form at the bottom.
ALL boxes must be ticked to proceed with the test.

The intended benefit is to test for the presence of coronavirus at the time of the test.

I agree to undergo a nose and throat swab to test for the presence of SARS-CoV-2, the current strain of coronavirus that causes COVID-19.
I have read and understood the patient information leaflet entitled “Coronavirus testing Throat and Nose Swab for COVID 19” version dated 26.9.20.
I understand that this test is as accurate as stated in the above patient information leaflet.
I accept there are risks and unwanted effects of this test including discomfort and minor bleeding.
I agree to enter the Government’s track and trace system if the test is positive.
I understand that another option is to not have this test at all.
I understand that I can have 3 possible outcomes: positive, negative and inconclusive.
I have had the opportunity to ask any questions that I have, and these have been answered fully.
I accept that the turnaround times for the tests are approximate and that GMR is not responsible for failures of courier services or laboratories. GMR cannot therefore guarantee that test results will be available by a specific time.
I agree to continue following government advice no matter what the test results show:A positive test result in an asymptomatic person should be taken as indicating COVID19 infection, and the person should immediately enter 10 days’ self-isolation, and their household members 14 days’ household isolation, in line with Government advice.A patient with a positive test result must be immediately directed to have another test via the national testing programme to ensure they enter the Test and Protect system quickly.A negative test result in an asymptomatic person does not rule out the possibility of infection, that they are incubating the infection or the possibility that they have been exposed to the infection after the test was taken. Therefore, individuals should continue to follow FACTS’ guidance (Face coverings in enclosed spaces, avoid crowded places, clean your hands and surfaces regularly, Two-metre social distancing and Self-isolate and book a test if you develop coronavirus symptoms).
I confirm I wish to proceed with the test.

SIGNED:

I confirm that I do not have any covid symptoms or have been in contact with anyone covid positive within the last 14 days.