COVID-19 TESTING: PCR, IMMUNOASSAY, SEROLOGY TEST CONSENT FORM Cadillac Fairview LAB AND IMAGING SERVICES INC.

Please read the information below and then complete the COVID-19 test consent form.

COVID-19 is an infectious illness caused by a newly discovered coronavirus. For many, the illness is mild or does not produce symptoms; however, the elderly, those with underlying medical problems (such as heart disease, diabetes, chronic respiratory disease, and cancer), and those who are constantly in contact with others in a close manner are more likely to develop a serious illness that may result in hospitalization or even death. We, at Cadillac Fairview LAB & IMAGING SERVICES INC., are offering you a COVID-19 test (Serology and/or PCR test) in order to screen for, prevent, and expedite the recovery of our society.

Privacy Notice

We are collecting your test sample and other personal information to determine if you have COVID-19 and to provide you with information on your results. Your personal information will be collected for the purpose of identification, matching the sample to the individual and creating a test label. You are not legally required to provide this data, but if you do not provide this information, we cannot test you. The only people who will have access to private information, such as your name and medical information, will be Cadillac Fairview LAB & IMAGING SERVICES INC., and, if necessary their partnering laboratories and if applicable, the following entities: Health Canada, local public health unit, or their contractors to conduct disease investigations or other public health activities, or other persons authorized by law. Please note, Cadillac Fairview LAB & IMAGING SERVICES INC. is undertaking the work on behalf of the Ministry of Education and will be sharing aggregated information with the Ministry, but not personal information.

Please carefully read and sign the following Informed Consent:

You certify that you have read and understood the attached COVID-19 Post-test Instructions, and that you have had the opportunity to ask questions about the test. You have also been informed of the risks and benefits associated with the test, including the possibility of slight discomfort or an incorrect result. If you undergo testing, you acknowledge that you did so voluntarily. If you decline testing, you understand that you may carry or transmit COVID-19, even if you do not have symptoms.

You also understand that Cadillac Fairview LAB & IMAGING SERVICES INC. is not liable for the test results.

I authorize Cadillac Fairview LAB & IMAGING SERVICES INC. to conduct collection and testing for COVID-19 for PCR, Immunoassay or Serology test, as ordered by an authorized medical provider, public health official or employer.
I authorize my test results to be disclosed to the local public health unit, or to any other governmental entity as may be required by law.
I acknowledge that a positive test result is an indication that I must self- isolate and follow any other directions as prescribed by local health officials in an effort to avoid infecting others.
I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree, that I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.
I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. Negative results of the test indicate the lack of current infection, but do not mean that I cannot be infected in the future.
I understand that Cadillac Fairview labs Inc is limited to administering the COVID- 19 test. Cadillac Fairview assumes no liability for third party service contracts outside of this limited role.
I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks. I have been given an opportunity to ask questions before I sign. I voluntarily agree to this testing for COVID-19.
I, the undersigned acknowledge and accept the appointment of school staffing to act as temporary custodians of younger children for the purposes of identification purposes only when a parent/guardian is not present for testing.
Please be aware that test results are not clinically significant and do not provide you with the right to disobey any orders and/or recommendations of government any municipal officials and Public Health or any other authorities. I have read and understand the above statement.

SANTA @ CF RICHMOND CENTRE