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Create a 4 digit number to verify your test results.

PATIENT CONSENT:
My signature below constitutes my acknowledgment that the benefits, risks, and limitations of this testing have been explained to my satisfaction by a qualified healthcare professional.
I understand, that this COVID testing site is being medically supervised by LV Imaging. I will be contacted by phone through a Telemedicine phone call, if I test positive for SAR-COV2 (PCR), to receive instructions or treatment if needed.
I have been given the opportunity to ask questions before I sign, and I have been told that I can ask questions at any other time. I voluntarily agreed to the test. If the signature is other than the patient’s signature, print name.
I hereby expressly waive and release any and all claims, now known or hereafter known, against EZ TESTING NOW, and its officers, directors, employees, agents, affiliates, members, successors, and assigns, on account of injury, death, or property damage arising out of or attributable to my participation in the testing, whether arising out of the negligence of EZ TESTING NOW or any other release, and forever release and discharge the company and all other releases from liability under such claims.
I intend my signature to be the required evidence of my assent to release all liability completely and unconditionally for the greatest extent allowed by law.
I authorize EZ TESTING NOW/Medberry Health PLLC, or one of its employees, agents, or affiliates to contact me to discuss my visit for a provider assessment with telecommunications.
If you are having difficulty breathing or an emergency call 911 or go to the nearest emergency room.

Symptoms

(Please Select One)

Fever :
  No  Yes
Cough :
  No  Yes
Shortness of breath:
  No  Yes
Congestion :
  No  Yes
Lost of Taste :
  No  Yes
Body Aches :
  No  Yes
Nausea/Vomiting :
  No  Yes
Have you been in contact with someone who tested positive for COVID-19 ?
 No    Yes
Insured Not Insured

 
 
I certify all information is true and correct.
 
ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize payment to TEXAS STAR BIO MED LLC/Marquis Labs LLC. I represent that I have insurance coverage and do hereby authorize EZ TESTING NOW and TEXAS STAR BIO MED LLC to release and obtain all information necessary to secure payment of said benefits. If my insurance fails to pay TEXAS STAR BIO MED LLC for any reason, I agree to pay all unpaid balances. By signing below, I acknowledge that I have read and fully understood all the terms of this agreement.


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Provided by Shaddai Solutions, LLC
August 15 2022 10:29:42.