COVID19 Rapid Test Consent Form

You are receiving this form because Prosper Home Care is alerting you to potential Covid-19 exposure. Prosper Home Care advises that you shelter in place and follow all CDC precautionary guidelines to protect yourself and others from the possible spread of Covid-19. These measures include wearing a mask, frequent hand washing, wearing gloves, not touching your face or eyes and keeping a minimum of 6 feet of distance between you and others whenever possible. Please refer to www.cdc.gov for the most up to date Covid-19 information. If the test provided through Prosper Home Care indicates positive for any Covid 19 antibody, we advise you seek a laboratory reviewed Covid test ASAP.

By signing this form you acknowledge that Prosper Home Care can not guarantee that the results of these tests to be 100% accurate. Signing this form also serves as acknowledgement that will hold Prosper Home Care, it’s owners and all affiliates “Harmless” against any potential liability claims. Be well.

Please indicate your affiliation with Prosper Home Care. *

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Date of Birth * +

Gender *

Race *

Ethnicity *

Place a checkmark next to each symptom that you are currently experiencing. If no symptoms are present, please check the box "No Current Symtpoms." *

Cough	Fever
Headache	Sore Throat
Myalgia	Anosmia
Nausea/Diarrhea/Vomiting	No Current Symptoms

Signature of Test Taker or Legal Guardian *

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