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Anti-body COVID-19 Test
Administered at the point of care
Pre-register your COVID-19 test
May we contact you via email?
Cell phone number
May we contact you via sms?
Date of birth (mm/dd/yyyy)
Last four digits of your SSN
Health Care Service Corporation (HCSC)
Molina Healthcare Inc.
Guidewell Mut Holding
California Physicians Service
Independence Health Group Inc.
Blue Cross of California
Blue Cross Blue Shield of Michigan
Blue Cross Blue Shield of New Jersey
Blue Cross Blue Shield of North Carolina
Health Net of California, Inc.
UPMC Health System
Blue Cross Blue Shield of Massachusetts
Blue Cross Blue Shield of Tennessee
Insurance Patient ID
Insurance Group ID
Company, most recent employer or school
Organizational ID (i.e. Student or employer ID)
Reason for testing
Worried about my health
Want to get back to work
Do you currently have symptoms of COVID-19? (Click all that apply)
Shortness of breath or difficulty breathing
Persistent pain or pressure in the chest
New confusion or inability to arouse
Bluish lips or face
Repeated shaking with chills
New loss of taste or smell
Date of Symptoms Start
Have you been in contact with someone diagnosed with COVID-19?
Yes within 1 week
Yes within last 2 weeks
Yes within last 3 weeks
Date of last health exam or COVID-19 test (mm/dd/yyyy)
Have you been tested for COVID-19?
I tested POSITIVE for COVID-19
I tested NEGATIVE for COVID-19
I never tried to be tested
I tried but was unable to secure a test
I agree to provide the use of my de-identified biospecimen for research purposes to improve COVID-19 testing and contribute to scientific research in strict compliance with Health Insurance Portability and Accountability Act (HIPAA), Institutional Review Board (IRB) and all applicable regulatory and ethical guidelines.
WAIVER AND GENERAL RELEASE OF LIABILITY
"You" means the person who by accepting this Agreement is receiving a medical test. "We" and "Us" means Power Analytics Global Corporation, a Delaware corporation and its affiliates. You hereby acknowledge and are aware that You are accepting this Agreement in anticipation of receiving a medical test for COVID-19 antibodies. You are voluntarily participating in these activities and assume all risk of injury that might result therefrom. You understand that the testing process and test results have inherent risks and uncertainties. You acknowledge and agree that there are no guarantees as to the sufficiency or accuracy of the tests. You agree to strictly follow the instructions given by the testing associate during the testing process. You hereby acknowledge that the testing associate may need to touch or otherwise make physical contact with You in order to administer the test. You acknowledge and accept that such contact is intended to be professional and will not be construed or interpreted to be inappropriate, and You hereby consents to such physical contact. You further agrees that if, at any time, You are not comfortable with the testing associate making physical contact, You are responsible for requesting termination of the services. You expressly release Us in connection with the good faith administration of the medical tests described herein. You agree to hold Us harmless, including Our agents, contractors, members, managers, employees, successors and assigns and all other persons and entities associated with Us from any claims related to or arising out of or in connection with the activities described herein. You further acknowledge that You have the express authority to enter into this Waiver and General Release.
Accept and Submit