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COVID19 Testing Registration Form

CompleteCare Contact Information

www.completecarenj.org

856-451-4700

Patient Consent

You are authorizing a nasopharyngeal swab for COVID-19 testing as ordered by your physician or authorized healthcare provider (legal dependent’s physician or authorized healthcare provider). You further understand, agree, certify, and authorize the following: 1.You understand that if you visited a healthcare provider other than Completecare Health Network, the prescription or laboratory orders given to you by your doctor will be replaced with an identical order being given by the licensed physicians or healthcare providers of CompleteCare Health Network. You authorize the CompleteCare Health Network to collect the specimen (nasopharyngeal swab). 2.The CompleteCare Health Network has contracted with LapCorp for laboratory analysis and report of my or my dependent’s specimen. You authorize LapCorp to perform testing on your specimen. 3.You understand that processing of the specimen and results may take between 3 to 4 days. 4.The CompleteCare Health Networkwill release the results of my test only to the physician or authorized healthcare provider who ordered testing. 5.You understand that the physician or authorized healthcare provider who wrote the prescription or laboratory orders will be responsible for providing the testing results, interpreting test results, explaining testing limitations, and providing any additional diagnostic or clinical services.

By clicking the box marked “yes” below and attending the drive thru testing event on my scheduled date, I agree to the Consent and acknowledge, understand, agree, certify, and/or authorize the information above and further agree to hold harmless the Cumberland County Health Department, CompleteCare Health Network, LabCorp, and the County of Cumberland, including its employees, agents, and contractors from any and all liability and claims.

You can email yourself a copy of your registration at the bottom of the confirmation page after you click submit.