Consent Form for Rapid Antigen Test for COVID-19 and Flu A+B

Please carefully read the following informed consent notice and complete, sign and submit the authorization to test for COVID-19 and Flu A+B. Upon submission, refresh the page if you would like to submit the consent form for another child.

  1. I understand that COVID-19 and flu A+B testing of the below-named student will be conducted through BD Triplex test provided by the Washington State Department of Health and acknowledge that the Fact Sheet for Individuals for the test has been made available to me.
  2. I understand that the ability of the below-named student to receive testing is limited to the availability of test supplies.
  3. I understand the entity performing the test is not acting as the below-named student’s medical provider. Testing does not replace treatment by a medical provider. I assume complete and full responsibility to take appropriate action with regards to the test results, including seeking medical advice, care, and treatment from a medical provider or other health care entity if I have questions or concerns, if the below-named student develops symptoms of COVID-19 and flu A+B, or if the below-named student’s condition worsens.
  4. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 and flu A+B test result.
  5. I understand it is my responsibility to inform the below-named student’s health care provider of a positive test result, and that a copy will not be sent to the below-named student’s health care provider for me.
  6. I understand that the antigen test result will be available in 15-30 minutes.
  7. I understand and acknowledge that a positive antigen test result is an indication that the below-named student needs to self-isolate to avoid infecting others.
  8. I have been informed of the test purpose, procedures, and potential risks and benefits. I will have the opportunity to ask questions before proceeding with a COVID-19 and flu A+B test. I understand that if I do not wish for the below-named student to continue with the COVID-19 and flu A+B diagnostic test, I may decline the test.
  9. I understand that to ensure public health and safety and to control the spread of COVID-19 and flu, the test results may be shared without my individual authorization.
  10. I understand that the test results will be disclosed to the appropriate public health authorities as required by law.
  11. I understand that I may withdraw my consent to the testing at any time before it is performed.

St. John School Consent Form for Rapid Antigen Test for COVID-19 and Flu A+B

Student Name(Required)
Student Birthdate(Required)
Parent/Guardian Name(Required)
I consent to authorize the above-named student to undergo COVID-19 and flu A+B testing.(Required)
Today's Date(Required)