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Covid-19 Testing Consent 

Completition of this form is required upon requesting a COVID test appointment. There is a $40 standard COVID service fee with or without insurance. Requested time slot is not guaranteed.

Gender
Ethnicity
Are you insured?
I consent to:
I give permission for my results to be given to:
Method of Payment

($40 standard COVID service fee with or without insurance)

Requested time slot is not guaranteed.

I understand that Mobile Medical Associates (MMA) may be required by law to send results to the CDC, Health Department, or other Federal offices. I consent to have my results emailed or texted to the information above. I understand that these Covid Tests are not 100% accurate and could give false positive or false negative results.
RAPID ANTIBODY: This test has been granted Emergency Use Authorization (EAU) by the FDA - Lot # COV20030057 EXP- 03/2022. Negative results do not rule out SARS-CoV-2 infection. If acute infection is suspected, direct testing for SARS-CoV-2 is necessary. Results from antibody testing should not be used to diagnose or exclude SARS-CoV-2. 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. Mobile Medical Associates hereby disclaims liability for accuracy of test results, any physical harm caused through the use of testing and/or the reliance of test results, and disclaims any third-party liability for the use of the Premier Biotech, Inc. Covid-19 IgG/IgM Rapid Test.

Thank you for scheduling your COVID-19 Test with MMA.  

 

A member from our testing team will contact you by 8pm on the day prior to your requested test date. Due to the high volume of testing requests, we are unable to guarantee specific time slots.  We will do our very best to accommodate your schedule. Our hours of operation are from 8am to 5pm Monday-Friday.

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Please note: Unless authorized by a Mobile Medical Associates staff member the maximum tests permitted per household is 10.

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