Employer / Group Name: __________________________ Location: _______________ Employee Family
COVID-19 IgG Antibody & RT-PCR Test Request Form
Please complete this form and provide a copy of insurance card and identification for at the time of collection.
Laboratory Personnel FOR OFFICE USE ONLY
Today’s Date:
Location Name:
Clinician Name:
Patient Information: COMPLETED BY PATIENT
First Name:
Last Name:
Zip Code:
Sex: □ Male □ Female
Additional Information required for testing:
Does the patient live or work in a congregate setting (e.g., long-term care facility, shelter, group home, prison, jail)
□ YES □ NO
Facility Name:
Employee Occupation:
Does the patient receive dialysis? YES □ NO
Date of symptom onset: □ None
Does the patient have any underlying conditions?
Symptoms Observed:
□ None
□ Runny nose
□ Unknown
□ Pregnant
□ Tiredness
Loss of smell
□ Diabetes
□ Chronic Lung Disease
Dry Cough
□ Hypertension
Chronic Liver Disease
Body Ache
Loss of Appetite
Cardiac Disease
Chronic Kidney Disease
Nasal Congestion
□ Other
Has the patient been tested for influenza?
Result: Positive □ Negative
Test Type: Rapid □ PCR
Has the patient been tested for any other viral respiratory illness?
Has the patient been tested for COVID-19?
Result: Positive □ Negative
Test Type: Rapid □ PCR
I hereby acknowledge full and complete consent for testing and make request for:
□ RT-PCR Test and/or □ SARS-Cov2 IgG Antibody Test (CHECK ONE OR BOTH)
I hereby acknowledge full and complete consent to and make request for a SARS-Cov2 IgG Antibody test. I am physically able to have this blood draw and have never
had an adverse reaction to any phlebotomy services. I hereby request and authorize PMH Laboratory, Inc. designated subcontractor who is an independent nurse/ healthcare
staffing agency, not directly affiliated with PMH Laboratory, Inc., to collect this sample for me or the person named above for whom I am the legal guardian. I hereby
release The PMH Laboratory, Inc. its principals, directors, members, employees, affiliates, suppliers, providers, subcontractors, successors, agents, their respective
insurance carriers, and the location sponsoring this clinic/program, its principals, directors, employees, affiliates, successors, or agents from any and all liability, injury or
damage whatsoever arising from, or in any way connected with, this SARS-CoV-2 IgG Antibody Test or the administration of same including, but not limited to, acts of
negligence. I authorize my medical information herein, including tests results, to be shared with my physician/insurance/employer. The PMH Laboratory, Inc., will use
and disclose your personal and health information to treat you, to receive payment for the care we provide, to public health agencies as required, and for our other health
care operations which generally include those activities we perform to improve quality care. We have prepared a detailed NOTICE OF PRIVACY AND
CONFIDENTIALITY PRACTICES to help you better understand our policies in regard to your personal health information. I acknowledge that I have received a copy
of the Notice of Privacy and Confidentiality Practices. I agree to remain in the general area for at least 5 minutes after collection of samples. Please provide a copy of
this form to your physician and/or healthcare provider for your medical records. This test is for informational purposes only and to be discussed with your health
care professional. The PMH Laboratory, Inc., is not providing you with medical advice nor are they responsible for any outcome in your care or treatment. Please keep
in mind that a positive result does not mean you are immune or cannot become re-infected. This test was developed, and its performance characteristics determined by
PMH Laboratory, Inc. This test has not been FDA cleared or approved. This test has been authorized by FDA under an Emergency Use Authorization (EUA). This test
has been validated in accordance with the FDA's Guidance Document (Policy for Diagnostics Testing in Laboratories Certified to Perform High Complexity Testing
under CLIA prior to Emergency Use Authorization for Coronavirus Disease-2019 during the Public Health Emergency) issued on April 20, 2020. FDA independent
review of this validation is pending. This test is only authorized for the duration of time the declaration that circumstances exist justifying the authorization of the
emergency use of in vitro diagnostic tests for detection of SARS-CoV-2 virus and/or diagnosis of COVID-19 infection under section 564(b)(1) of the Act, 21 U.S.C.
360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.
PATIENT SIGNATURE:_______________________________________________________ DATE:______________________________
5862 Edinger Ave Huntington Beach CA 92649 (562) 592-2890 Office (909) 803-9790 Fax
CLIA 05D2137011 ◊ STATE CLF351210 ◊ COLA 028736
Rahil R. Khan, MD Laboratory Director
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