Please read the following document carefully and sign:

a. I authorize this Covid-19 Test Center "Family Rehab" to acquire a nasopharyngeal sample and to examine the sample for the detection of Covid-19 as required by public health agencies.

b. I authorize my results to be communicated to any government agency or as required by law. I also authorize the communication of my positive results to airlines and cruise ships as required by Miami-Dade County Government. This authorization is valid for a period of one (1) year from the day it was signed.

c. I understand that a positive result is an indication that I should quarantine, wear a mask or cover my face so as not to infect others

d. I understand that this laboratory is not acting as my physician, and does not replace the need for a physicians care when required. I also accept responsibility for my results and what they mean. I agree to obtain a medical consultation with my physician to clarify any concerns I have, to obtain care / treatment if my condition worsens and I understand that like other diagnostic procedures, there is a possibility of a false positive or false negative test for Covid-19.

e. I understand that "Family Rehab" are in no way responsible if the client / patient does not arrive on time for their flight / misses it or is quarantined upon arrival at their destination. I understand that the responsibility for choosing the type of proof necessary for my destiny is mine and mine alone.

f. I understand that "Family Rehab" are in no way responsible if the client / patient does not arrive on time for their flight / misses it or is quarantined upon arrival at their destination. I understand that the responsibility to choose the type of test necessary for my destiny is mine and mine alone.

g. I understand and agree that "Family Rehab" do not provide cancellations or refunds once the test has been administered.I, the patient / client, have been informed of the purpose of the test, the procedures, the possible benefits and risks. I have also received a copy of this consent. I have been given the opportunity to ask questions before signing. I accept this Covid-19 test voluntarily, for my personal, business or travel needs

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.

Please select who will participate ...

This contract is for YOU only

Name

Name*

Middle name

Last name*

Telephone*

Gender:

Date of birth*

Additional information

Passport #*

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

Fever*

Yes
No

Cough (new onset or worsening of chronic cough) *

Yes
No

Throat pain*

Yes
No

Difficulty breathing (dyspnea)*

Yes
No

Nausea **

Yes
No

Abdominal pain *

Yes
No

Chills *

Yes
No

Headache*

Yes
No

Muscle aches (myalgia)*

Yes
No

Fatigue *

Yes
No

Runny nose (rhinorrhea) *

Yes
No

Vomiting*

Yes
No

Diarrhea (3 loose stools / day) *

Yes
No

Loss of smell *

Yes
No

Loss of taste*

Yes
No

Other specify

Date of onset of the symptoms

Lab test

Test type: nasal swab (PCR) / antigen / SARS-COV-2

Select the test*

ANTIGEN
PCR
RT-PCR
PCR-24hrs
RT-PCR 24hrs
Antigen FLU A & B
Multiplex Viral Detection

Address

State / Province

Country

Are you traveling?

FLIGHT/CRUISE INFORMATION

Airline/CruiseLine*

Destination*

Flight/Cruise # *

Insurance Information

How did you hear about us?

Option

Friends
Airline Staff
Airport Advertisement
Google
Other

Name of Minor

Name*

Middle name

Last name*

Telephone*

Gender:

Birth Date of Minor*

Additional Information of the Minor

Passport #

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

Fever*

Yes
No

Cough (new onset or worsening of chronic cough) *

Yes
No

Sore Throat*

Yes
No

Difficulty breathing (dyspnea)*

Yes
No

Nausea *

Yes*
No

Abdominal pain *

Yes
No

Chills *

Yes
No

Headache*

Yes
No

Muscle aches (myalgia)*

Yes
No

Fatigue *

Yes
No

Runny nose (rhinorrhea) *

Yes
No

Vomiting*

Yes
No

Diarrhea (3 loose stools / day) *

Yes
No

Loss of smell *

Yes
No

Loss of taste*

Yes
No

Other specify

Date of onset of the symptoms

Lab test

Test type: nasal swab (PCR) / antigen / SARS-COV-2

Select the test*

ANTIGEN
PCR
RT-PCR
PCR-24hrs
RT-PCR 24hrs
Antigen FLU A & B
Multiplex Viral Detection

Address of the Minor

State / Province*

Country*

Are you traveling?

FLIGHT/CRUISE INFORMATION

Airline/CruiseLine*

Destination*

Flight/Cruise # *

Insurance Information

How did you hear about us?

Option

Friends
Airline Staff
Airport Advertisement
Google
Other

Parent Or Guardian Name

Name*

Middle name

Last name*

Telephone*

Date Birth Of Gaurdian

Electronic signature acceptance*

By checking ts box, you agree that your electronic signature will be used in place of your handwritten signature. If this is not what you want, you have the right to ask to sign a paper copy instead. By checking this box, you warve this right Upon acceptance, you may request in writing that we send you a paper copy of the electronic record. You will not have to pay anything for such a copy, and you do not need any special software or hardware to view it. Your acceptance of electronic signature for any document will remain in effect until such time as you notify us in veriting that you no longer wish to use electronic signature. The revocation of your acceptance will not entall any penalty for you Your acceptance of electronic signature for any document will remain in effect until such time as you notify us in veriting that you no longer wish to use electronic signature. The revocation of your acceptance will not entall any penalty for you Your acceptance of electronic signature for any document will remain in effect until such time as you notify us in veriting that you no longer wish to use electronic signature. The revocation of your acceptance will not entall any penalty for you

Please select who will participate ...

This agreement is for YOU and a MINORS

This agreement is for a MINORS

This contract is for YOU only

Account #

Name

Date of birth*

Additional information

Lab test

Address

Email address*

Are you traveling?

FLIGHT/CRUISE INFORMATION

Insurance Information

How did you hear about us?

Account #

Name of Minor

Birth Date of Minor*

Additional Information of the Minor

Lab test

Address of the Minor

Email address*

Are you traveling?

FLIGHT/CRUISE INFORMATION

Insurance Information

How did you hear about us?

Parent Or Guardian Name

Electronic signature acceptance*