Patient Information
Insurance Type
Provider Information
COVID-19 Tests
Select the order code(s) for this requisition
Virus Detection:
Virus Antibody:
DX Codes: (select all that apply)
Custom State Required Questions
General Consent for COVID-19 Testing in the state of Colorado
By submitting this form, I attest that:
- I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through anterior nares or saliva swabs, as authorized by a medical provider or public health official.
- I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.
- I understand that I am not creating a patient relationship with the testing location by participating in testing. I understand that Mako is not acting as my medical provider. Testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate action with regards to my test results. I agree 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.
- I have been informed about the test purpose, procedures, possible benefits, and risks. I have been given the opportunity to ask questions before I sign, and I may ask additional questions at any time.
- My consent for this screening test for COVID-19 is knowing and voluntary.
