104 Edgware Road
I authorise TSM Health -Kings Medical Centre to order COVID-19 Test for me for the extraction of coronavirus RNA and real-time polymerase chain reaction (RT-PCR) analysis of the RNA to detect COVID-19 infection and genomic sequencing of all positive donor samples with a cycle threshold (CT) value of < 30
I acknowledge that in the event that my COVID-19 Test has a positive result then, as is required by law pursuant to the Public Health (Control of Disease) Act 1984 and the Health Protection (Notification) Regulations 2010, my test result and personal details, which may include my name, date of birth, gender, home address, telephone number, NHS number, occupation, place of work, ethnicity and the fact that I have tested positive for COVID 19 must be communicated to Public Health England, either directly by the laboratory.
I understand that the Laboratory will be unable to erase my test results, which are required as evidence of clinical practice.
I understand that TSM Health- Kings medical Centre will be responsible for receiving my results and communicating them to me.
I understand that the COVID-19 Test is to be used for screening purposes only as a convenient and confidential way of me getting tested quickly for a COVID-19 infection. The results are not intended to replace medical advice, nor should they be used as a full diagnosis, or to prescribe medication without consulting an appropriate medical professional.
I confirm that I have read and understood the purpose for which the sample and data collected will be used.