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COVID-19 is an infectious illness caused by a newly discovered coronavirus. George Mason University is providing me with the voluntary opportunity to get tested for COVID-19.
I consent and authorize George Mason University (GMU) to conduct collection, testing and analysis of samples from me for the purpose of a Center for Disease Control (CDC) and/or Food and Drug Administration (FDA) approved Coronavirus (COVID-19) test. Analysis of the samples will be conducted in partnership with a third-party laboratory. If I undergo testing, I acknowledge that I did so voluntarily. I understand that I may carry or transmit COVID-19, even if I do not have symptoms. I have been informed about the test purpose and procedures.
I understand possible risks include:
I understand potential benefits include:
I understand George Mason University is not acting as my medical provider unless as a student, I request Student Health Services to be my provider. This testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results.
I understand that my test results will be treated as confidential medical records. If my test results in a positive or suspected positive diagnosis of COVID-19:
I understand this authorization is in effect until both the Federal Public Health Emergency declaration and the Virginia State of Emergency are revoked. I also understand that I may revoke or cancel this authorization at any time by submitting a written statement to firstname.lastname@example.org except to the extent that action has already been taken based on this authorization.
I agree to receive this form electronically and provide my authorization by electronic signature. I acknowledge that I am capable of saving, printing or otherwise retaining this form if I wish to do so.
I am eighteen (18) years of age or older.
After selecting submit below, you will be redirected to a online scheduling system to set up an appointment. Please see your email for a link to instructions on how to make an appointment using the registration portal.
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