Step 04

Please carefully read and sign the following Informed Consent:

I authorize Consult Rx Pharmacy. and its affiliates to conduct screening of pooled nasal samples for COVID-19 testing. I certify that I have voluntarily provided a fresh and unadulterated specimen for analytical testing. The information I have provided to Consult Rx Pharmacy is accurate.
n the event of a positive pool, I authorize individual testing of my child’s submitted sample as ordered by an authorized medical provider or public health official. I understand that a performing CLIA Laboratory may use my specimen and any testing performed on that specimen for research and development so long as the information has been de-identified pursuant to law. I authorize my child’s individual test results to be disclosed to Mt. San Antonio College, the county, state, or any other governmental entity as may be required by law.
I further authorize a performing CLIA Laboratory to release the results of this testing to the ordering authorized healthcare provider or facility.
I acknowledge that results of screening tests alone are not sufficient to detect or rule out the possibility that an individual has been exposed to or is infected with COVID-19
I understand that World Back to Work, Inc. and its affiliates are not acting as a medical provider, this testing does not replace treatment by my child’s medical provider, and I assume complete and full responsibility to take appropriate action with regard to my child’s test results. I agree to seek medical advice, care, and treatment from my child’s medical provider if I have questions or concerns.
I understand that there may be a potential for false positive or false negative test results. I and/or my child have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent form. 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 and/or my child voluntarily agree to this testing for COVID-19.

For purposes of this consent “I,” “me,” “my,” and “you” refer to the consent-giver or the Patient as the context requires. The consent-giver must be the Patient if the Patient possesses the legal capacity to consent (e.g., is not an unemancipated minor). Alternatively, the consent-giver must be an individual with the legal capacity to consent for the Patient, such as a parent, legal guardian, or authorized health care surrogate.

(“Vaccine”) to the patient for whom this appointment is being made (“Patient”). I understand the “Consult Rx Pharmacy Vaccine Provider” is either a pharmacist, pharmacy intern, or pharmacy technician, employed or contracted by Consult Rx Pharmacy or an affiliate or subsidiary of Consult Rx Pharmacy. I hereby acknowledge that Consult Rx Pharmacy has provided me with a Vaccine Information Statement, Emergency Use Authorization, or fact sheet (“Guidance”) containing information about the Vaccine including information on certain adverse reactions that the Patient may experience as a result of receiving the Vaccine. I further acknowledge I have carefully read and understood this Guidance prior to the Patient’s receipt of the Vaccine. I will ask the Consult Rx Pharmacy Vaccine Provider or, if I prefer, the Consult Rx Pharmacy pharmacist on duty if that pharmacist is not the Consult Rx Pharmacy Vaccine Provider, any questions I may have about the Vaccine or about information in the Vaccine Information Statement prior to the Patient’s receipt of the Vaccine. By allowing the Consult Rx Pharmacy Vaccine Provider to administer the Vaccine to the Patient, I agree I fully understand all risks and benefits in connection with the Vaccine and all my questions have been answered to my satisfaction. I understand I may choose for the Patient not to receive the Vaccine and will not be charged for the cancellation.

I have truthfully answered all the questions regarding the Patient’s medical history that are listed above. I understand that if I answered a question with a “Yes,” there is an increased likelihood that the Patient will experience an adverse reaction from the administration of the Vaccine. After careful consideration, I believe that the benefits of the Patient receiving the Vaccine outweigh the risks associated with receiving the Vaccine and I have decided to allow the Consult Rx Pharmacy Vaccine Provider to administer the Vaccine to the Patient.

I have provided true, complete, and accurate information identifying the Patient’s applicable health care plan/insurance coverage, if any. I authorize Consult Rx Pharmacy to submit a claim to the Patient’s health care plan/insurer for this service and hereby assign the Patient’s rights to health care plan/insurance benefits to collect any available benefits due with respect to such claim to Consult Rx Pharmacy, its affiliate, or subsidiary. I will be financially responsible for any co-pays, coinsurance, and deductibles for the requested services as well as for any services not covered by the Patient/s health care plan/insurance benefits.

I authorize Consult Rx Pharmacy to use and/or disclose such information about the Patient, including any medical related information that I provide to Consult Rx Pharmacy, its affiliate or subsidiary, or that is created or received by Consult Rx Pharmacy, its affiliate or subsidiary, that Consult Rx Pharmacy reasonably determines is necessary to receive payment for its services, carry out treatment for the Patient, or conduct healthcare operations. This authorization includes disclosures to regulatory agencies, Medicare, Medicaid, health plans, insurers, pharmacy benefit managers, claims processors, billing companies, interpreters, and other persons involved in the Patient’s treatment or payment for the Patient’s treatment, as well as any applicable immunization registry, health information exchange, or adverse event database, or any designee, for public health reporting or care coordination. Depending upon applicable law, I may prevent the disclosure of certain vaccination information to the registry or exchange by completing an opt-out form that is available in the pharmacy. I understand that even if I do not consent or if I withdraw my consent, applicable law may permit certain disclosures of my vaccination information to or through the registry or exchange or to government agencies.

Consult Rx Pharmacy shall not, at any time, or to any extent allowable by applicable law, be liable, responsible, or in any way be accountable for any loss, injury, death, or damage suffered or sustained by the Patient or me or any other person at any time in connection with, or as a result of, the administration of the Vaccine to the patient by the Consult Rx Pharmacy Vaccine Provider. I, for myself and for the Patient, and for my and the Patient’s heirs, executors, personal representatives, and assigns, hereby release Consult Rx Pharmacy, its affiliates and subsidiaries, and the employees and contractors (including specifically, without limitation, the administering Consult Rx Pharmacy Vaccine Provider), as well as Consult Rx Pharmacy and its affiliates’ and subsidiaries’ agents and representatives from any and all claims arising out of, in connection with, or in any way related to the Patient’s receipt of the Vaccine as and to the full extent allowed by applicable law.

By providing your mobile phone number or email, you expressly request and authorize Consult Rx Pharmacy, its affiliates and subsidiaries, to deliver or cause to be delivered calls and unencrypted messages to you at the number or email provided, by using an automatic telephone dialing system or an artificial or pre-recorded voice or other means, for any and all purposes related to the Patient’s treatment, including but not limited to prescriptions and reminders and information regarding completing the second dose of the vaccination, as well as related to payment, insurance, healthcare operations, quality improvement, utilization, disease or case management, or for telemarketing and advertising care alternatives and other benefits, products, and services that may be of interest. You understand that texts and push notifications are not secure. If others intercept the messages or access the device, they will be able to see confidential health information. You understand that you need not agree as a condition to purchase any goods or services.

By signing below, I certify that I have read, understood, and agreed to all the statements above and that either (a) I am the Patient, am at least 18 years old and do not have a guardian, or (b) I am the Patient's parent/guardian with authority to consent and agree on behalf of the Patient.

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Please carefully read and sign the following Informed Consent:

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