COVID TESTING & VACCINATION CONSENT

Rockdale County Schools and Free Covid Testing and Vaccine Centers have designed the Covid Mitigation Plan for testing. The goal of the plan is to decrease the spread of Covid-19 for the students, staff, teachers, families, and community. Legal guardians: please fill out the attached consent form for patients below the age of 18 and adults under legal guardianship.

Student First Name*

Student Last Name*

Grade*

Date of Birth*

School District*

Email*

Your Name*

Relationship to Student*

Required Uploads (photos ok!)*

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Max. file size: 900 MB, Max. files: 3.

1) Parent / Guardian Identification (ID, DL, or Passport)
2) Insurance Card (front and back), if applicable.

Consent Waiver and Authorization

Consent/Release and Waiver As the parent or legal guardian of the above-named student, I hereby give my consent to Top Dog Solutions, LLC dba Free Covid Testing and Vaccine Centers (TDS Solutions) to conduct a test on the above-named student for the COVID-19 virus through an anterior nasal swab/nasopharyngeal swab and related professional medical services including any ancillary services related thereto to accomplish the same. The risks associated with drawing bodily fluid for laboratory examination include, but are not limited to, infection and bleeding. I further grant permission for TDS employees or contractors to treat the student for any condition that arises on site out of the testing services agreed to under this consent, if necessary, which permission gives TDS employees or contractors the right to treat such conditions in their sole discretion if within their capabilities but does not require them to do so. I understand that TDS employees or contractors providing services on behalf of Rockdale County Schools are not necessarily physicians or medical doctors, are not employees or agents of TDS, and that TDS is not liable for their acts or omissions. I understand that the services provided by TDS relate to the performance of an isolated diagnostic test and are not intended to be a complete medical examination or create any physician-patient relationship. By supplying my home phone number/mobile phone number/email address, I acknowledge that TDS or a third-party automated outreach and messaging system may notify me of a pending appointment, missed appointment, lab results, or deliver any other health care message by call, email, or text message. I consent for TDS or the school listed above, or a third party acting on its behalf, to call or text me at any phone number associated with my account, including through pre-recorded/automated voice and text messages. I understand that my cell phone carrier may charge me for these text messages and that I will be offered an easy way to opt out of these automated calls or text messages. I acknowledge that I have reviewed TDS Notice of Privacy Practices located on freecovidtesting.us and that TDS and its licensed and other health care professionals may use and release medical information obtained during any visit for purposes of treatment, payment, and health care operations. Such disclosure may include information provided to any insurance carrier, employer, government or social service agency or other provider of medical benefits for purposes of reimbursement for any part of expenses incurred and for the purpose of evaluation and processing claims for payment for services provided to the student. I authorize and assign all payments of such insurance benefits directly to Top Dog Solutions, LLC. Understanding the risks and alternatives, I hereby fully release, acquit and discharge Top Dog Solutions, LLC and all of its employees, contractors, owners, agents and representatives from any and all liability associated with the performance of the diagnostic test or tests consented to hereunder. Authorization to Disclose Protected Health Information I authorize Top Dog Solutions, LLC to use or disclose the above-named student’s test results of the COVID 19 virus test ("Protected Health Information") to Rockdale County Public Schools (including the School) and any individual involved in the operation of Atlanta Public Schools, including, without limitation, designated officials and the Superintendent, to inform such individuals of whether the student has been tested positive or negative for the COVID-19 virus and to facilitate contact tracing with respect to preventing the spread of the COVID-19 virus. This authorization expires 12 (twelve) months from the date of signatures noted below. I UNDERSTAND THAT: The Protected Health Information used or disclosed under this authorization may be subject to redisclosure by the receiver and no longer protected by the Standards for Privacy of Individually Identifiable Health Information. Treatment, payment, enrollment in a health plan or eligibility for benefits may not be conditioned on whether I sign this authorization. If I have any questions about the disclosure of my Protected Health Information, I can contact Top Dog Solutions at jtabares@topdogoperations.com I may revoke this authorization in writing except to the extent that Top Dog Solutions, LLC has previously used or disclosed the Protected Health Information in reliance on this authorization. To revoke this authorization, I must deliver/mail a signed written statement clearly stating that I revoke this authorization, to Jennifer Tabares at Free Covid Testing and Vaccine Centers (Top Dog Solutions) 4295 Interstate Drive Macon, GA 31210.*

Consent/Release and Waiver

As the parent or legal guardian of the above-named student, I hereby give my consent to Top Dog Solutions, LLC dba Free Covid Testing and Vaccine Centers (TDS Solutions) to conduct a test on the above-named student for the COVID-19 virus through an anterior nasal swab/nasopharyngeal swab and related professional medical services including any ancillary services related thereto to accomplish the same.

The risks associated with drawing bodily fluid for laboratory examination include, but are not limited to, infection and bleeding. I further grant permission for TDS employees or contractors to treat the student for any condition that arises on site out of the testing services agreed to under this consent, if necessary, which permission gives TDS employees or contractors the right to treat such conditions in their sole discretion if within their capabilities but does not require them to do so.

I understand that TDS employees or contractors providing services on behalf of Rockdale County Schools are not necessarily physicians or medical doctors, are not employees or agents of TDS, and that TDS is not liable for their acts or omissions. I understand that the services provided by TDS relate to the performance of an isolated diagnostic test and are not intended to be a complete medical examination or create any physician-patient relationship.

By supplying my home phone number/mobile phone number/email address, I acknowledge that TDS or a third-party automated outreach and messaging system may notify me of a pending appointment, missed appointment, lab results, or deliver any other health care message by call, email, or text message. I consent for TDS or the school listed above, or a third party acting on its behalf, to call or text me at any phone number associated with my account, including through pre-recorded/automated voice and text messages. I understand that my cell phone carrier may charge me for these text messages and that I will be offered an easy way to opt out of these automated calls or text messages.

I acknowledge that I have reviewed TDS Notice of Privacy Practices located on freecovidtesting.us and that TDS and its licensed and other health care professionals may use and release medical information obtained during any visit for purposes of treatment, payment, and health care operations. Such disclosure may include information provided to any insurance carrier, employer, government or social service agency or other provider of medical benefits for purposes of reimbursement for any part of expenses incurred and for the purpose of evaluation and processing claims for payment for services provided to the student. I authorize and assign all payments of such insurance benefits directly to Top Dog Solutions, LLC.

Understanding the risks and alternatives, I hereby fully release, acquit and discharge Top Dog Solutions, LLC and all of its employees, contractors, owners, agents and representatives from any and all liability associated with the performance of the diagnostic test or tests consented to hereunder.

Authorization to Disclose Protected Health Information

I authorize Top Dog Solutions, LLC to use or disclose the above-named student’s test results of the COVID 19 virus test ("Protected Health Information") to Rockdale County Public Schools (including the School) and any individual involved in the operation of Atlanta Public Schools, including, without limitation, designated officials and the Superintendent, to inform such individuals of whether the student has been tested positive or negative for the COVID-19 virus and to facilitate contact tracing with respect to preventing the spread of the COVID-19 virus. This authorization expires 12 (twelve) months from the date of signatures noted below.

I UNDERSTAND THAT:

The Protected Health Information used or disclosed under this authorization may be subject to redisclosure by the receiver and no longer protected by the Standards for Privacy of Individually Identifiable Health Information.

Treatment, payment, enrollment in a health plan or eligibility for benefits may not be conditioned on whether I sign this authorization.

If I have any questions about the disclosure of my Protected Health Information, I can contact Top Dog Solutions at jtabares@topdogoperations.com

I may revoke this authorization in writing except to the extent that Top Dog Solutions, LLC has previously used or disclosed the Protected Health Information in reliance on this authorization. To revoke this authorization, I must deliver/mail a signed written statement clearly stating that I revoke this authorization, to Jennifer Tabares at Free Covid Testing and Vaccine Centers (Top Dog Solutions) 4295 Interstate Drive Macon, GA 31210.

I agree consent waivers, authorizations and forms.*

Parent/Guardian Signature*

Date