I authorize my or (as a guardian, my ward, listed on this form as 'interest') healthcare information to be released to parties of interest, (ie Public Health Departments, Schools, Athletic programs, Daycare centers, Shelters and etc.).
The release is intended solely for the purpose of assessing my covid-19 health status as it relates to my/interest participation.
The testing site or entity, Quiclinics Medical Partners and/or their authorized affiliates, make no guarantees that the information will not be redisclosed by recipient to a third party. Accepting this disclaimer/consent is voluntary but rejecting consent may affect condition under which service is provided. You may also revoke this consent at any time in writing.
By checking the box and/or proceeding, I certify that I have read the disclaimer and consented to the rules. This checked consent serves the same purpose as if it were a written consent, signed by the party.