I have signed this form freely and voluntarily, and I am legally authorized to make healthcare-related decisions for the child named above.
I consent for my child to be tested for COVID-19 infection by Synergy Diagnostic Laboratory Inc.
I understand that this consent form will be valid, unless I notify the designated contact person from Synergy Diagnostic Laboratory Inc in writing that I revoke my consent.
I understand that if I revoke this consent form, it will not have any effect on actions taken by Synergy Diagnostic Laboratory Inc before they received my revocation.
I understand that my child’s test results, and other information may be disclosed as permitted by law.
I understand that if I am a student age 18 or older or may otherwise legally consent for my own health care, references to “my child” refer to me and I may sign this form on my own behalf.
I have provided accurate and up-to-date contact information below in the event I need to be contacted regarding this consent for my child.
