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Patient Authorization and Consent to Disclose Test Results to Your Employer

Form Last updated: December 15, 2020

Your employer has hired GoLab to provide SARS-CoV-2 testing to its employees as a workplace risk-reduction safety measure. 

By digitally signing this consent form, you authorize GoLab to release to your employer your SARS-CoV-2 test results.

You are not required to consent to the releases of these test records. However, if you do not consent, GoLab will be unable to perform SARS-CoV-2 testing on you as part of your employer’s sponsored group testing event.

 

GoLab can make no representations about how your COVID-19 test results may be used by your employer after they are released to your employer.

Based on the above, I certify that I have read the foregoing Informed Consent, had opportunities to ask questions, agree and accept all of the terms above, and voluntarily consent as noted above.

 

{Digital Signature}

Signed: ______________________________

Print Name: ____________________________

Date and Time of Signature: ____________________