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2. First Name*
3. Last Name*
5. Address1*
7. Address2
9. City*
10. State*
11. Zip*
13. Contact Phone Number*
14. Email Address*
16. Date of Birth*
    MM/DD/YYYY
17. Date You Intend to Test
    Date You Intend to Test
    (Testing occurs on Mondays, Wednesdays, and Thursdays)
21. 1. I am the _________ of the individual named below.*

    1. Individual

    1. Parent

    1. Legal Guardian
23. 2. I authorize the Southwest Community Health Center (SWMTCHC) to perform testing on my (or my dependent's) specimen.*

    1. Yes

    1. No
25. 3. I understand that processing the specimen and results will depend on state lab turn around times. Currently up to 8 days. (7/14/2020)
27. 4. The Southwest Montana Community Health Center (SWMTCHC) will release the results of my test if positive to the physician or authorized healthcare provider who ordered testing.
29. 5. I understand my (child’s/dependent’s) test results will be disclosed to the county and state health entity as required by law.
31. 6. FOR EMPLOYEES OF THIS FACILITY ONLY: I authorize public health authorities to release test results to a facility contact to process said release of test results.
33. 7. I acknowledge that a positive test result is an indication that I (my child / dependent) may be required to isolate to avoid infecting others. Should the test result be positive, I (my child / dependent) will be contacted by local public health with further instruction.
35. 8. I understand that a patient relationship with Southwest Montanan Community Health Center (SWMTCHC) is not created by participating in testing. I understand the testing unit is not acting as my or (my child’s/dependent’s) medical provider. Testing does not replace treatment by a medical provider. I will take appropriate action with regards to my (child’s/dependent’s) test results. I will seek medical advice, care and treatment from my (child’s/dependent’s) medical provider with questions or concerns, or if a health condition worsens.
37. 9. I hereby consent for myself (child/dependent), my (child’s/dependent’s) heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily agree to have my sample taken and analyzed and hereby waive any and all rights, claims, or causes of action of any kind whatsoever arising out of my participation in this activity, and do hereby release SWMTCHC and its agents for any injury that I may suffer as a direct result of my participation in this activity, including traveling to and from any location related to this activity.
39. Verbal consent given, consent to have staff sign for me r/t infection control at testing event.

    1. Yes

    1. No
43. Patient Name*
45. Parent or Guardian (if applicable)*
    Mark "N/A" if completing the form as an individual.
47. Date*
    Date
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field