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Please carefully read and sign the following Informed Consent:

a. I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab or blood draw, as ordered by an authorized medical provider or public health official.

b. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law. I also authorize the disclosure of my test results, in the case of a positive test result, to the airlines as required by the Miami-Dade Aviation Department. This authorization is valid for one (1) year from the date this authorization is signed.

c. I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others.

d. I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. 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.

e. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.

f. Customer understands and acknowledges that Family Rehab and Communitel are not responsible in any way if the customer misses, is quarantine and/or is late to their flight. It is the ultimate responsibility of the customer to determine and confirm with the airline and/or destination country regarding which type of test is required.

g. Customer understands and acknowledges that there shall be no cancellations and/or refunds given once the test is performed.

h. Customer understands and acknowledges that Family Rehab cannot guarantee that customers will receive their test results electronically due to possible spotty internet connections and email security protocols that may reject or send test results to a spam folder. Family Rehab highly recommends that each customer requests and obtains a printed copy of their test results.

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 COVID-19.

First Customer's Name

First Name*

Middle Name

Last Name*

Phone*
First Customer's Date of Birth*
First Customer's Additional Information

Passport #

Have you had any of the following symptoms in the past 14 days?

Fever*
No
Yes
Cough (new onset or worsening of chronic cough)*
No
Yes
Sore throat*
No
Yes
Shortness of breath (dyspnea)*
No
Yes
Nausea*
No
Yes
Abdominal pain*
No
Yes
Chills*
No
Yes
Headache*
No
Yes
Muscle aches (myalgia)*
No
Yes
Fatigue*
No
Yes
Runny nose (rhinorrhea)*
No
Yes
Vomiting*
No
Yes
Diarrhea (>3 loose stools/day)*
No
Yes
Loss of smell?*
No
Yes
Loss of taste?*
No
Yes

Other, specify

Onset date for earliest symptom

Laboratory Testing

Test Type: Nasal Swab(PCR)/Antigen/SARS-COV-2

Choose Test*
ANTIGEN
PCR
RT-PCR
PCR-24hrs
RT-PCR-24hrs
First Customer's Signature*
Second Customer's Name

First Name*

Middle Name

Last Name*
Second Customer's Date of Birth*
Second Customer's Additional Information

Passport #

Have you had any of the following symptoms in the past 14 days?

Fever*
No
Yes
Cough (new onset or worsening of chronic cough)*
No
Yes
Sore throat*
No
Yes
Shortness of breath (dyspnea)*
No
Yes
Nausea*
No
Yes
Abdominal pain*
No
Yes
Chills*
No
Yes
Headache*
No
Yes
Muscle aches (myalgia)*
No
Yes
Fatigue*
No
Yes
Runny nose (rhinorrhea)*
No
Yes
Vomiting*
No
Yes
Diarrhea (>3 loose stools/day)*
No
Yes
Loss of smell?*
No
Yes
Loss of taste?*
No
Yes

Other, specify

Onset date for earliest symptom

Laboratory Testing

Test Type: Nasal Swab(PCR)/Antigen/SARS-COV-2

Choose Test*
ANTIGEN
PCR
RT-PCR
PCR-24hrs
RT-PCR-24hrs
Third Customer's Name

First Name*

Middle Name

Last Name*
Third Customer's Date of Birth*
Third Customer's Additional Information

Passport #

Have you had any of the following symptoms in the past 14 days?

Fever*
No
Yes
Cough (new onset or worsening of chronic cough)*
No
Yes
Sore throat*
No
Yes
Shortness of breath (dyspnea)*
No
Yes
Nausea*
No
Yes
Abdominal pain*
No
Yes
Chills*
No
Yes
Headache*
No
Yes
Muscle aches (myalgia)*
No
Yes
Fatigue*
No
Yes
Runny nose (rhinorrhea)*
No
Yes
Vomiting*
No
Yes
Diarrhea (>3 loose stools/day)*
No
Yes
Loss of smell?*
No
Yes
Loss of taste?*
No
Yes

Other, specify

Onset date for earliest symptom

Laboratory Testing

Test Type: Nasal Swab(PCR)/Antigen/SARS-COV-2

Choose Test*
ANTIGEN
PCR
RT-PCR
PCR-24hrs
RT-PCR-24hrs
Fourth Customer's Name

First Name*

Middle Name

Last Name*
Fourth Customer's Date of Birth*
Fourth Customer's Additional Information

Passport #

Have you had any of the following symptoms in the past 14 days?

Fever*
No
Yes
Cough (new onset or worsening of chronic cough)*
No
Yes
Sore throat*
No
Yes
Shortness of breath (dyspnea)*
No
Yes
Nausea*
No
Yes
Abdominal pain*
No
Yes
Chills*
No
Yes
Headache*
No
Yes
Muscle aches (myalgia)*
No
Yes
Fatigue*
No
Yes
Runny nose (rhinorrhea)*
No
Yes
Vomiting*
No
Yes
Diarrhea (>3 loose stools/day)*
No
Yes
Loss of smell?*
No
Yes
Loss of taste?*
No
Yes

Other, specify

Onset date for earliest symptom

Laboratory Testing

Test Type: Nasal Swab(PCR)/Antigen/SARS-COV-2

Choose Test*
ANTIGEN
PCR
RT-PCR
PCR-24hrs
RT-PCR-24hrs
Fifth Customer's Name

First Name*

Middle Name

Last Name*
Fifth Customer's Date of Birth*
Fifth Customer's Additional Information

Passport #

Have you had any of the following symptoms in the past 14 days?

Fever*
No
Yes
Cough (new onset or worsening of chronic cough)*
No
Yes
Sore throat*
No
Yes
Shortness of breath (dyspnea)*
No
Yes
Nausea*
No
Yes
Abdominal pain*
No
Yes
Chills*
No
Yes
Headache*
No
Yes
Muscle aches (myalgia)*
No
Yes
Fatigue*
No
Yes
Runny nose (rhinorrhea)*
No
Yes
Vomiting*
No
Yes
Diarrhea (>3 loose stools/day)*
No
Yes
Loss of smell?*
No
Yes
Loss of taste?*
No
Yes

Other, specify

Onset date for earliest symptom

Laboratory Testing

Test Type: Nasal Swab(PCR)/Antigen/SARS-COV-2

Choose Test*
ANTIGEN
PCR
RT-PCR
PCR-24hrs
RT-PCR-24hrs
Sixth Customer's Name

First Name*

Middle Name

Last Name*
Sixth Customer's Date of Birth*
Sixth Customer's Additional Information

Passport #

Have you had any of the following symptoms in the past 14 days?

Fever*
No
Yes
Cough (new onset or worsening of chronic cough)*
No
Yes
Sore throat*
No
Yes
Shortness of breath (dyspnea)*
No
Yes
Nausea*
No
Yes
Abdominal pain*
No
Yes
Chills*
No
Yes
Headache*
No
Yes
Muscle aches (myalgia)*
No
Yes
Fatigue*
No
Yes
Runny nose (rhinorrhea)*
No
Yes
Vomiting*
No
Yes
Diarrhea (>3 loose stools/day)*
No
Yes
Loss of smell?*
No
Yes
Loss of taste?*
No
Yes

Other, specify

Onset date for earliest symptom

Laboratory Testing

Test Type: Nasal Swab(PCR)/Antigen/SARS-COV-2

Choose Test*
ANTIGEN
PCR
RT-PCR
PCR-24hrs
RT-PCR-24hrs
Seventh Customer's Name

First Name*

Middle Name

Last Name*
Seventh Customer's Date of Birth*
Seventh Customer's Additional Information

Passport #

Have you had any of the following symptoms in the past 14 days?

Fever*
No
Yes
Cough (new onset or worsening of chronic cough)*
No
Yes
Sore throat*
No
Yes
Shortness of breath (dyspnea)*
No
Yes
Nausea*
No
Yes
Abdominal pain*
No
Yes
Chills*
No
Yes
Headache*
No
Yes
Muscle aches (myalgia)*
No
Yes
Fatigue*
No
Yes
Runny nose (rhinorrhea)*
No
Yes
Vomiting*
No
Yes
Diarrhea (>3 loose stools/day)*
No
Yes
Loss of smell?*
No
Yes
Loss of taste?*
No
Yes

Other, specify

Onset date for earliest symptom

Laboratory Testing

Test Type: Nasal Swab(PCR)/Antigen/SARS-COV-2

Choose Test*
ANTIGEN
PCR
RT-PCR
PCR-24hrs
RT-PCR-24hrs
Eighth Customer's Name

First Name*

Middle Name

Last Name*
Eighth Customer's Date of Birth*
Eighth Customer's Additional Information

Passport #

Have you had any of the following symptoms in the past 14 days?

Fever*
No
Yes
Cough (new onset or worsening of chronic cough)*
No
Yes
Sore throat*
No
Yes
Shortness of breath (dyspnea)*
No
Yes
Nausea*
No
Yes
Abdominal pain*
No
Yes
Chills*
No
Yes
Headache*
No
Yes
Muscle aches (myalgia)*
No
Yes
Fatigue*
No
Yes
Runny nose (rhinorrhea)*
No
Yes
Vomiting*
No
Yes
Diarrhea (>3 loose stools/day)*
No
Yes
Loss of smell?*
No
Yes
Loss of taste?*
No
Yes

Other, specify

Onset date for earliest symptom

Laboratory Testing

Test Type: Nasal Swab(PCR)/Antigen/SARS-COV-2

Choose Test*
ANTIGEN
PCR
RT-PCR
PCR-24hrs
RT-PCR-24hrs
Ninth Customer's Name

First Name*

Middle Name

Last Name*
Ninth Customer's Date of Birth*
Ninth Customer's Additional Information

Passport #

Have you had any of the following symptoms in the past 14 days?

Fever*
No
Yes
Cough (new onset or worsening of chronic cough)*
No
Yes
Sore throat*
No
Yes
Shortness of breath (dyspnea)*
No
Yes
Nausea*
No
Yes
Abdominal pain*
No
Yes
Chills*
No
Yes
Headache*
No
Yes
Muscle aches (myalgia)*
No
Yes
Fatigue*
No
Yes
Runny nose (rhinorrhea)*
No
Yes
Vomiting*
No
Yes
Diarrhea (>3 loose stools/day)*
No
Yes
Loss of smell?*
No
Yes
Loss of taste?*
No
Yes

Other, specify

Onset date for earliest symptom

Laboratory Testing

Test Type: Nasal Swab(PCR)/Antigen/SARS-COV-2

Choose Test*
ANTIGEN
PCR
RT-PCR
PCR-24hrs
RT-PCR-24hrs
Tenth Customer's Name

First Name*

Middle Name

Last Name*
Tenth Customer's Date of Birth*
Tenth Customer's Additional Information

Passport #

Have you had any of the following symptoms in the past 14 days?

Fever*
No
Yes
Cough (new onset or worsening of chronic cough)*
No
Yes
Sore throat*
No
Yes
Shortness of breath (dyspnea)*
No
Yes
Nausea*
No
Yes
Abdominal pain*
No
Yes
Chills*
No
Yes
Headache*
No
Yes
Muscle aches (myalgia)*
No
Yes
Fatigue*
No
Yes
Runny nose (rhinorrhea)*
No
Yes
Vomiting*
No
Yes
Diarrhea (>3 loose stools/day)*
No
Yes
Loss of smell?*
No
Yes
Loss of taste?*
No
Yes

Other, specify

Onset date for earliest symptom

Laboratory Testing

Test Type: Nasal Swab(PCR)/Antigen/SARS-COV-2

Choose Test*
ANTIGEN
PCR
RT-PCR
PCR-24hrs
RT-PCR-24hrs
Customer'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*
FLIGHT/CRUISE INFORMATION
Airline/CruiseLine*

Destination *

Flight/Cruise # *
How did you hear about us?
Options:*
A friend
Airline Staff
Airport Advertising
Google
Other

If Other, please specify.
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Additional Information

Passport #

Have you had any of the following symptoms in the past 14 days?

Fever*
No
Yes
Cough (new onset or worsening of chronic cough)*
No
Yes
Sore throat*
No
Yes
Shortness of breath (dyspnea)*
No
Yes
Nausea*
No
Yes
Abdominal pain*
No
Yes
Chills*
No
Yes
Headache*
No
Yes
Muscle aches (myalgia)*
No
Yes
Fatigue*
No
Yes
Runny nose (rhinorrhea)*
No
Yes
Vomiting*
No
Yes
Diarrhea (>3 loose stools/day)*
No
Yes
Loss of smell?*
No
Yes
Loss of taste?*
No
Yes

Other, specify

Onset date for earliest symptom

Laboratory Testing

Test Type: Nasal Swab(PCR)/Antigen/SARS-COV-2

Choose Test*
ANTIGEN
PCR
RT-PCR
PCR-24hrs
RT-PCR-24hrs
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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