Please complete this form and it will be associated with the specimen for testing you provide.
The tests performed by Net Medical Xpress Solutions, Inc. require a prescription by a licensed physician to perform. In order to prescribe the test, you must agree to enter into a doctor patient relationship with the doctor prescribing the test. Under legislative relief granted during the duration of the pandemic, you have the right to enter into that relationship via Telemedicine and by signing this form, you agree to such a relationship via Telemedicine.
You hereby give Net Medical Xpress Solutions, Inc. permission to collect the sample or samples necessary to perform the testing
The Food and Drug Administration (FDA) has authorized this test for use under an Emergency Use Authorization during the duration of the COVID-19 pandemic. The test to be performed is authorized for use only at a certificate that carries a CLIA certification including a CLIA certificate of waiver.
In late December 2019, investigation of a cluster of pneumonia cases of unknown origin in Wuhan, China resulted in identification of a novel coronavirus. The virus is distinct from both severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV), although closely related. Early epidemiologic findings indicate COVID-19 may be less severe (1) than SARS or MERS, but evidence suggests that the virus is more contagious than its predecessors. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a newly identified pathogen and it is assumed there is no existing human immunity to the virus. Everyone is assumed to be susceptible, although there may be risk factors that increase an individuals illness severity.
Based on epidemiologic reports of the outbreak in China, those at highest risk for severe disease and death include people aged over 60 years and those with underlying conditions such as hypertension, diabetes, cardiovascular disease, chronic respiratory disease, and cancer. Disease in children appears to be relatively mild, and growing evidence that a significant proportion of infections across all age groups are asymptomatic.
Epidemiological reports from the field are demonstrating a growing importance of presymptomatic and asymptomatic infections from two lines of evidence: the serial interval of COVID-19 appears to be close to or shorter than its median incubation period and clusters linked to presymptomatic and asymptomatic index cases (2)(3). CSTE realizes that field investigations will involve evaluations of persons with no symptoms and these individuals will need to be counted as cases.
There may be no direct benefits to you (or your child) from having this test done. This test may help to find the virus in people who do not yet have all the signs of COVID-19. If people with the COVID-19 virus limit contact with other people, this can prevent others from getting sick. By having this test done, you may lower the chance of spreading the virus from you (your child) to your family or others. Use of this test could also help us to know more about this virus to help stop the spread of this illness. The results of this test, along with other information, may help your (your childs) doctor take better care of you (your child).
If this test is positive, does that mean I (my child) have COVID-19 and what are the risks of a positive result?
There is a small chance that this test may give a positive result for the COVID-19 virus when the virus is not there (false positive). If your (your childs) result from this test is positive:
If this test is negative, does that mean I (my child) do not have COVID-19?
This test may give a negative result when you (or your child) actually have the virus (false negative). A false negative result should not have an effect on your (or your childs) care. A negative test does not prove that a person does or does not have the COVID-19 virus. No changes in your medical care or how you interact with people around you should be based on a negative result.
To do an Antigen test, we need a nasal or a nasophraengyal swab which involves swabbing an area through your or your child's nose. This test directly checks for antigen protiens associated with the virus. To do an Antibody test, we need 2 drops of blood from you or your child. This blood may be taken by a needle stick or poke in your (or your childs) finger. This test looks for evidence that the body is fighting the infection (antibodies), and sometimes it takes time for the body to make antibodies to fight the virus.
When we take your (or your childs) blood, the needle stick or poke may pinch or sting or cause bleeding or a bruise.
There are no other ways of obtaining a sample for antibody testing for COVID-19 other than obtaining a blood (or serum) source. Antigen and Molecular tests require nasal or nasophryngeal swabs. There may be other FDA approved similar rapid laboratory tests using COVID-19 as well. Tests exist that can use other bodily fluids as samples such as saliva but none has authorization for use at CLIA waived labs as of the date of this test.
We will keep all facts about you (your child) as private as the law allows. CDC, FDA the Local/State Health Department staff, and the person(s) who ordered your test (such as your doctor) may see your/your childs results. When we present or publish papers about these tests, neither you (nor your child) will be named. Upon your request, we will send test results only to the email address you provide.
If you (your child) are harmed as a result of taking the samples, Net Medical will not pay the costs for hospital and medical care. You, your insurer, Medicare or Medicaid will need to pay those costs. You (or your child) do not give up any legal rights that otherwise would be available to you (or your child).
It is your choice to have this testing done on you (your child). If you refuse to have the testing done, you (or your child) will not lose the right to get health care because of not having results from these tests.
We will not do human genetic testing or HIV testing or any other testing other than the expressed purpose (testing for COVID-19 Antigen, RNA Presence, or IgM and IgG COVID-19 Antibodies) of this test on the samples you provide.
Please call your doctor if you have any questions about this testing. If you have questions about your (or your childs) rights as a participant in this testing program or if you feel you have been harmed or injured by taking part in the program, please call the Net Medical Lab Director 505-255-1999. Leave a message including your (or your childs) name, phone number and someone will call you back as soon as possible.
You will want a receipt for your questionnaire answers. The receipt will contain a barcode that you will use the next time you get tested.
There are three options for getting your receipt:
When you are satisfied with your answers, hit Submit and you are finished!