Miami International Airport H Doors

2100 NW 42 Ave. Terminal H Doors 19-20 Departures Miami, Florida 33126

Tel: (786) 269-0763

Fax: (786) 206-9142

Please carefully read and sign following Informed Consent:

a. I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab or blood draw, as ordered by an authorized medical provider or public health official.

b. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law. I also authorize the disclosure of my test results, in case of a positive test result, to the airlines as required by the Miami-Dade Aviation Department. This authorization is valid for one (1) year from the date this authorization is signed.

c. I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others.

d. I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.

e. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.

f. I understand and acknowledge that Family Rehab and Communitel are not responsible in any way if the customer misses, is quarantine and/or is late to their flight. It is the ultimate responsibility of the customer to determine and confirm with the airline and/or destination country regarding which type of test is required.

g. I understand and acknowledge that there shall be no cancellations and/or refunds given once the test is performed.

h. I understand and acknowledge that Family Rehab cannot guarantee that customers will receive their test results electronically due to possible spotty internet connections and email security protocols that may reject or send test results to a spam folder. Family Rehab highly recommends that each customer requests and obtains a printed copy of their test results.

I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.

Please select who will be participating.