Please carefully read and sign the following Informed Consent:
I authorize Covid Clinic to conduct collection and testing for Monkeypox virus with the BioeXsen Monkeypox Virus qPCR test. The purpose of this test is to aid in diagnosing me based on my medical history and current symptoms.
The procedure will include one the following testing methods based on the symptoms criteria provided by the CDC, WHO and other public health agencies:
The procedure will be performed in a private examination room, with two licensed healthcare professionals (defined as PA, NP, physician, LVN, CNA, MA, and/or RN). The examination room will not have any visibility from the outside. I understand that my genital and/or anal region may need to be examined for testing if lesions are present in those locations.
Risks of testing include, but are not limited to the following: discomfort at the testing locations of skin lesions. Benefits of testing: aiding in the diagnosis of my symptoms, in order for me to receive proper medical treatment and recommendations.
Treatment will be based on my symptoms, and any concurrent disease states, including other bacterial infections. Therapy will be at the discretion of the Driven Care provider.
I understand that I am responsible for giving allergy information and other medical history to my provider prior to receiving treatment. This is to aid the provider in avoiding possible complications of treatment.
I understand that the complications of any treatment are dependent upon the type of treatment and will be discussed with me by the Driven Care provider.
I understand that information about my results (not including any identifying data) may be compiled by Covid Clinic to establish local trends. This information may be shared with public health officials and community leaders, if necessary.
I understand that in order for my results to be processed, I need to speak and meet with a Driven Care provider (Physician, Nurse Practitioner, or Physician Assistant), via telemedicine. This meeting includes getting an assessment, and/or treatment and recommendations that are appropriate for my symptoms and test results. I acknowledge that I have also received the Telehealth Consent and Consent for Monkeypox Care Consultation and Treatment Service, which include the details on the telehealth and/or in person consultation for Monkeypox.
I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.
I understand that, as with any medical test, there is the potential for a false positive or false negative Monkeypox virus test result.
I understand and agree that I am financially responsible for all charges for any and all services rendered. This includes any medical service or visit, testing and any other screening ordered by the provider or staff
By signing this form, I consent to the use and disclosure of protected health information about me for treatment, payment and health care operations, and/or as required by law. I have the right to revoke this Consent, in writing, signed by me. However, such revocation shall not affect any disclosures already made in compliance with my prior Consent.
I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for Monkeypox virus.