EventScan - GMU Registration Page - March 7-14, 2021 (Destin, FL) - EventScan© - Rapid and PCR Testing for Monkeypox (mpox), Covid-19, Flu A/B, Group A Strep, H5N1 Bird Flu

March 14-20, 2021 (Naples, FL)

Event Host: Law & Economics Center, GMU Antonin Scalia Law School
Customer Rapid Testing Registration Form

Please complete all sections below to register for rapid testing services.
Test Type #1: COVID-19 PCR Test (Cheek Swab) - Ship by Mail

Please note: Testing results will be emailed to the customer using the email address indicated above.
Test Type #2: COVID-19 Rapid Test (Blood/Plasma or Antigen)

Please note: Testing results will be emailed to the customer using the email address indicated above.
Name *

First Name Last Name
Today's Date *

Month Day Year
Date
Date of Birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Allergy Information (Please check all that apply):

Latex Rubbing Alcohol

Customer Information Release and Consent Form

PLEASE ACKNOWLEDGE EACH SECTION BELOW WITH SIGNATURE
I understand that test results reported by ALLIED MOBILE SERVICES will be reported directly to me, in the manner chosen below. I further understand that it is my responsibility to consult my own medical doctor for interpretation, analysis, evaluation, and explanation of my test results. I understand that neither ALLIED MOBILE SERVICES nor its ordering physician will analyze, evaluate, critique or otherwise interpret the results of said tests. I agree that ALLIED MOBILE SERVICES, its officers, shareholders, directors, employed physicians, or its other agent or employee shall not be liable for any claims including, but not limited to, any claim arising out of or related to, inaccurate, uninterrupted, misinterpreted or results not received and do hereby expressly forever release and discharge all claims, demands, injuries, damage, actions or causes of action. YOUR SIGNATURE BELOW *

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I certify that I will not seek to be reimbursed by Medicare, Medicaid, Tricare or any other government insurer/payer. I agree that I am personally financially responsible for payment of fees for all tests ordered and collected by ALLIED MOBILE SERVICES unless paid for by the event host or my employer.Your Signature Below *

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I understand that the laboratory tests performed at ALLIED MOBILE SERVICES are done at my request. I further understand that a clinically trained employee of ALLIED MOBILE SERVICES who is insured to conduct testing will provide testing results. I also understand that ALLIED MOBILE SERVICES is a collection service and that the actual testing results will be provided by the test cartridge device. I understand and agree that ALLIED MOBILE SERVICES will report the results of the testing directly to me and the event host or employer. I consent and authorize that such disclosure may be made by fax, by mail or by direct pick-up. I understand and agree that the services provided by ALLIED MOBILE SERVICES and the test results will be maintained as confidential, protected health information by ALLIED MOBILE SERVICES as required by federal and state law. Your Signature Below *

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I understand that the test results may become part of my medical record. I understand that the test results may be reported to local, county, state or federal agencies as required by law. I also understand that an insurance company may discover the results of this testing by obtaining a copy of my medical record in accordance with the terms of my insurance policy(ies). I hereby consent to the release of my test results by ALLIED MOBILE SERVICES to me by email and the event host or employer I have designated. I understand that my test results will only be provided to other third parties upon my express consent.Your Signature Below *

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I understand services are paid for at the time that services are performed or paid by the event host or employer. No refunds or chargebacks will be accepted. Your Signature Below *

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All of the above has been discussed with me and I have had an opportunity to have any questions answered that I may have regarding my rights to privacy by an employee of ALLIED MOBILE SERVICES. I have received a copy of Notice of Privacy Practices, as required by HIPAA from ALLIED MOBILE SERVICES or I have chosen not to receive a copy.Your Signature Below *

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I have read and agreed to all the above terms. Your Signature Below *

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Today's Date *

Month Day Year
Date

COVID-19 Antibody/Antigen Test Informed Consent Form
INTRODUCTION: The COVID-19 Antibody / Antigen Test is used to determine if you have antibodies directed against SARS-CoV-2, the virus that causes COVID-19. A COVID-19 antibody/antigen test is able to detect if your body has developed antibodies to fight against the SARS-CoV-2 virus. This test can help you determine if you have ever been exposed to the virus, even if you were never diagnosed with COVID-19. However, it is important to emphasize that COVID-19 is a new disease, and the CDC has not concluded that the presence of antibodies made by the body to fight the disease will definitively ensure that a person will not contract COVID-19 again. The COVID-19 Antibody/Antigen Test is performed by drawing a drop of blood from your finger using a safety lancet. As with any other blood draw, you may have some discomfort at the site of the needle-stick and a small bruise may develop. FDA APPROVAL STATUS The FDA issued an Emergency Use Authorization for this test. > Negative results do not rule out SARS-CoV-2 infection, particularly in those who have been in contact with the virus. Follow-up testing with a molecular diagnostic should be considered to rule out infection in these individuals. > Results from antibody/antigen testing should not be used as the sole basis to diagnose or exclude SARS- CoV-2 infection or to inform infection status. > 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. Employers should not use the results of antibody/antigen testing as the sole decision for employee staffing and workplace safety. After reading this Informed Consent Form, if you have questions or would like to discuss the information provided, please talk to your healthcare provider. PLEASE SIGN AND ACKNOWLEDGE: I currently have no COVID-19 symptoms and have been asymptomatic for the last 14 days. I have read, understand, accept, and agree to the terms stated above regarding the COVID-19 Antibody Test. Your Signature Below *

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Name *

First Name Last Name
Today's Date *

Month Day Year
Date

Customer Authorization For Disclosure of Protected Health Information via Email
Name *

First Name Last Name
Today's Date *

Month Day Year
Date
Date of Birth *

Month Day Year
Date
I, the undersigned, authorize ALLIED MOBILE SERVICES to disclose or provide protected health information (laboratory or rapid testing results only) directly to me at the e-mail address I have provided below. I also understand that it is my responsibility to notify ALLIED MOBILE SERVICES of any change in this information. Any disclosure on e-mail is subject to the re-disclosure statement within this authorization. Your Signature Below *

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Email Address *
example@example.com
I authorize ALLIED MOBILE SERVICES to disclose the protected health information, my rapid test results, to the e-mail address I have indicated. This authorization is only effective for the visit date (“Today’s Date”) listed on this authorization form. You must submit a new authorization at each visit to ALLIED MOBILE SERVICES if you wish to have rapid test results sent to you by e-mail. As stated in our Notice of Privacy Practice, I have the right to revoke or terminate this authorization by submitting a written request to the facility. This can be done in person or by e-mailing a request to ALLIED MOBILE SERVICES at info@alliedmobile.us. RE-DISCLOSURE-I understand that ALLIED MOBILE SERVICES has no control over who may have access to the e-mail address I have listed to receive my protected health information. The information disclosed will no longer be protected by the requirements of the Privacy Rule and future discloser is not responsibility of ALLIED MOBILE SERVICES.Your Signature Below *

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Event Host Disclaimer
Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), Allied Mobile Services is taking extra precautions with the care of every guest attending a hosted event (collectively, the “Event”), including COVID-19 active virus testing, face coverings, increased air circulation for indoor activities, and enhanced sanitation/disinfecting procedures in compliance with CDC guidance. Your signature on this Liability Waiver and Acknowledgment Form recognizes the following: I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that there are preventative measures in place to reduce the spread of the Coronavirus/COVID-19. I further acknowledge there is no guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, event staff, and other event guests. I further acknowledge that despite receiving testing to indicate the presence of active COVID-19, the testing received today is not 100% accurate. Therefore, there is still risk of myself and/or other guests attending the Event of carrying and transmitting Coronavirus/COVID-19. I voluntarily attended the Event and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with procedures to reduce the spread while attending the Event. I hereby release and agree to hold George Mason University, George Mason University Antonin Scalia Law School, Allied Mobile Services, ILD, and EventScan© (the “Hosts”) harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the Hosts or that may otherwise arise in any way in connection with the Event. I understand that this release discharges the Hosts from any liability or claim that I, my heirs, or any personal representatives may have against the Hosts with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from the Hosts. Your Signature Below *

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Today's Date

Month Day Year
Date
Should be Empty:

March 14-20, 2021 (Naples, FL)

Customer Rapid Testing Registration Form

Test Type #1: COVID-19 PCR Test (Cheek Swab) - Ship by Mail

Test Type #2: COVID-19 Rapid Test (Blood/Plasma or Antigen)

Customer Information Release and Consent Form

COVID-19 Antibody/Antigen Test Informed Consent Form

Customer Authorization For Disclosure of Protected Health Information via Email

Event Host Disclaimer