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COVID-19 Consent Form

Device: BD Veritor System for Rapid Detection of SARS-CoV-2 

Indication: Qualitative detection of SARS-CoV-2 nucleocapsid antigens in nasal swabs from individuals who are suspected of COVID-19 by their healthcare provider within the first five days of the onset of symptoms. Emergency use of this test is limited to authorized laboratories using the BD Veritor Plus Analyzer Instrument.

Laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, that meet the requirements to perform high, moderate, or waived complexity tests. This test is authorized for use at the Point of Care (POC), i.e., in patient care settings operating under a CLIA Certificate of Waiver, Certificate of Compliance, or Certificate of Accreditation.

I understand and agree that local health guidelines include the reporting of positive test results to the County Health Department to enable contact tracing and limit spread of the disease and I hereby consent to such reporting in the event I test positive.

10 Minutes Rapid Detection of SARS-CoV-2 (COVID-19) N-Protein Antibodies Test Kit.

HealGen Scientific LLC offers lateral flow devices for the detection of IgG and IgM antibodies to the coronavirus N-protein in serum, plasma, and peripheral blood. An example of a lateral flow device is a home pregnancy test. They are easy to use and provide rapid results.

This rapid test is for in vitro diagnostic use, following guidance from the FDA for Emergency Use Authorizations of tests submitted for approval on March 16, 2020. The tests have not been reviewed by the FDA and results from antibody testing should not be used as the sole basis to diagnose or exclude SARS-CoV-2 (COVID-19) infection or to inform infection status.

IgG/IgA/IgM Antibody Detection Kit (Indirect ELISA)

N-Protein and S-Protein (S1 subunit, RBD) human antibody detection kits (Indirect ELISA method) for the semi-quantitative measurement of human IgG, IgA, or IgM antibody against SARS-CoV-2 in serum or plasma.

I am voluntarily on my free will, allow Relany LLC dba: CryoFit of Milwaukee to:

Blood Test Consent and Release Form.  I hereby consent to the drawing of a blood sample for the purpose of COVID-19 antibody test. I have had the opportunity to read and consider the Relany LLC Privacy Practices Notice to my satisfaction prior to consent. I accept that services, including counseling/explaining of results, might be rendered in a non-private setting. Furthermore, I hereby release and forever discharge for myself, my heirs, executors, administrators and assignees, Relany LLC and their employees, owners and representatives, as well as the company sponsoring this event and their agents, representatives, employees, successors, assignees, governing bodies, and advisory committees from any and all claims, demands, actions and causes of action, which may result from participation in this program. I understand and accept that: 1. Data derived from this test is to be considered preliminary only and does not constitute any kind of diagnosis. 2. The responsibility for initiating a follow-up examination to confirm results and obtain professional advice and medical treatment is mine and not that of Relany LLC or any other organization associated with this screening. 3. Relany LLC will keep my results strictly confidential and may release only aggregate data to my employer or other organizations. 4. Relany LLC will keep my results strictly confidential and may release my data to a 3rd party vendor, which will anonymize it before sending it to my employer for the purposes of wellness program development.

Today's Date: June 18, 2021

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?*
No
Yes
Have you or anyone in your household been tested for COVID-19?*
No
Yes
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?*
No
Yes
Have you or anyone in your household traveled in the U.S. in the past 21 days?*
No
Yes
Have you or anyone in your household traveled on a cruise ship in the last 21 days?*
No
Yes
Are you or anyone in your household a health care provider or emergency responder?*
No
Yes
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?*
No
Yes
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?*
No
Yes
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?*
No
Yes
Have you or anyone in your household been tested for COVID-19?*
No
Yes
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?*
No
Yes
Have you or anyone in your household traveled in the U.S. in the past 21 days?*
No
Yes
Have you or anyone in your household traveled on a cruise ship in the last 21 days?*
No
Yes
Are you or anyone in your household a health care provider or emergency responder?*
No
Yes
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?*
No
Yes
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?*
No
Yes
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?*
No
Yes
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?*
No
Yes
Have you or anyone in your household been tested for COVID-19?*
No
Yes
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?*
No
Yes
Have you or anyone in your household traveled in the U.S. in the past 21 days?*
No
Yes
Have you or anyone in your household traveled on a cruise ship in the last 21 days?*
No
Yes
Are you or anyone in your household a health care provider or emergency responder?*
No
Yes
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?*
No
Yes
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?*
No
Yes
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?*
No
Yes
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?*
No
Yes
Have you or anyone in your household been tested for COVID-19?*
No
Yes
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?*
No
Yes
Have you or anyone in your household traveled in the U.S. in the past 21 days?*
No
Yes
Have you or anyone in your household traveled on a cruise ship in the last 21 days?*
No
Yes
Are you or anyone in your household a health care provider or emergency responder?*
No
Yes
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?*
No
Yes
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?*
No
Yes
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?*
No
Yes
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?*
No
Yes
Have you or anyone in your household been tested for COVID-19?*
No
Yes
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?*
No
Yes
Have you or anyone in your household traveled in the U.S. in the past 21 days?*
No
Yes
Have you or anyone in your household traveled on a cruise ship in the last 21 days?*
No
Yes
Are you or anyone in your household a health care provider or emergency responder?*
No
Yes
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?*
No
Yes
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?*
No
Yes
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?*
No
Yes
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?*
No
Yes
Have you or anyone in your household been tested for COVID-19?*
No
Yes
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?*
No
Yes
Have you or anyone in your household traveled in the U.S. in the past 21 days?*
No
Yes
Have you or anyone in your household traveled on a cruise ship in the last 21 days?*
No
Yes
Are you or anyone in your household a health care provider or emergency responder?*
No
Yes
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?*
No
Yes
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?*
No
Yes
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?*
No
Yes
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?*
No
Yes
Have you or anyone in your household been tested for COVID-19?*
No
Yes
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?*
No
Yes
Have you or anyone in your household traveled in the U.S. in the past 21 days?*
No
Yes
Have you or anyone in your household traveled on a cruise ship in the last 21 days?*
No
Yes
Are you or anyone in your household a health care provider or emergency responder?*
No
Yes
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?*
No
Yes
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?*
No
Yes
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?*
No
Yes
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?*
No
Yes
Have you or anyone in your household been tested for COVID-19?*
No
Yes
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?*
No
Yes
Have you or anyone in your household traveled in the U.S. in the past 21 days?*
No
Yes
Have you or anyone in your household traveled on a cruise ship in the last 21 days?*
No
Yes
Are you or anyone in your household a health care provider or emergency responder?*
No
Yes
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?*
No
Yes
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?*
No
Yes
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?*
No
Yes
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?*
No
Yes
Have you or anyone in your household been tested for COVID-19?*
No
Yes
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?*
No
Yes
Have you or anyone in your household traveled in the U.S. in the past 21 days?*
No
Yes
Have you or anyone in your household traveled on a cruise ship in the last 21 days?*
No
Yes
Are you or anyone in your household a health care provider or emergency responder?*
No
Yes
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?*
No
Yes
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?*
No
Yes
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?*
No
Yes
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?*
No
Yes
Have you or anyone in your household been tested for COVID-19?*
No
Yes
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?*
No
Yes
Have you or anyone in your household traveled in the U.S. in the past 21 days?*
No
Yes
Have you or anyone in your household traveled on a cruise ship in the last 21 days?*
No
Yes
Are you or anyone in your household a health care provider or emergency responder?*
No
Yes
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?*
No
Yes
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?*
No
Yes
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?*
No
Yes
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?*
No
Yes
Have you or anyone in your household been tested for COVID-19?*
No
Yes
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?*
No
Yes
Have you or anyone in your household traveled in the U.S. in the past 21 days?*
No
Yes
Have you or anyone in your household traveled on a cruise ship in the last 21 days?*
No
Yes
Are you or anyone in your household a health care provider or emergency responder?*
No
Yes
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?*
No
Yes
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?*
No
Yes
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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