I am at least eighteen (18) years of age. I voluntarily consent and authorize AMC, and their
partners, any of their respective officers, directors, employees, representatives and agents to
conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test for myself
and/or my child(ren) and/or my legal dependent(s) as applicable. I recognize that I need medical
services and I voluntarily consent to treatment by the medical staff of the practice, as deemed
necessary in their judgment.
I understand that the type of test I am signing up for is a COVID-19 molecular reverse-transcriptase
polymerase chain reaction [PCR] test to detect the presence of viral RNA. The test will consist of a
collected nasal swab.
I understand that there are risks and benefits associated with undergoing a diagnostic test for
COVID-19. I understand that test results are not 100% accurate and there may be a potential for
false positive or false negative test results.
A positive molecular test for SARS-CoV-2 generally confirms the diagnosis of COVID-19; however, tests
may remain positive long after a patient is no longer infectious due to prolonged detection of RNA.
A negative test result may just mean that I was not infected at the time the test was done. I
understand that I could still become infected at a later point, so it is important to continue to
practice prevention measures such as physical distancing and washing my hands frequently. If I
continue to have symptoms associated with COVID-19, I will contact my medical provider.
I assume complete and full responsibility to take appropriate action with regards to my test results.
If I have questions or concerns regarding my results, or my condition gets worse, I agree I will
promptly seek advice and treatment from an appropriate medical provider.
I understand that the extent of the county's role will be determining whether the test is medically
appropriate. Should I receive positive test results, I will seek care from my own medical provider.
Having insurance is not required to receive a COVID-19 PCR test. If I have insurance information, I
have provided this, accurately and completely and understand this information will be used to bill
my insurance company for the cost associated with this test. I will not be charged for this test.
To the fullest extent permitted by law, I hereby release, discharge and hold harmless, the AMC clinic
without limitation, any of their respective officers, directors, employees, representatives and
agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of
or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure
of my COVID-19 test results.
I understand and agree that my COVID-19 test results may be sent to me by text message, telephone or
email by a lab or third-party organization, and I authorize the disclosure of my COVID-19 test
results to such organization. I understand and agree that my COVID-19 test results may be shared
with a Health Information Exchanges (HIE). An HIE is a community-wide information system used by
participating health care providers to share health information about you for treatment purposes.
Should you require treatment from a health care provider that participates in one of these exchanges
who does not have your medical records or health information, that health care provider can use the
system to gather your health information in order to treat you. For example, he or she may be able
to get laboratory or other tests that have already been performed or find out about treatment(s)
that you have already received.
By signing below, I (patient) agree to participate in the Guam Visitors Bureau’s free COVID-19
testing program for returning visitors. The information that I have provided is true and
correct. I understand that the Guam Visitors Bureau is not liable for any reactions, injuries,
bodily harm, or distress that may result from testing or late or indeterminate test results. I
authorize American Medical Center to release my patient information to include my results, copy
of either my passport, driver’s license, or birth certificate, copy of my arrival boarding pass,
and copy of my departure confirmation."
Medical Center（クリニック）に対し、旅行のためのPCR 検査に関連する私の患者情報
"아래에 서명함으로써, 본인 은/는 괌정부관광청의 PCR 검사비 지원 프로그램에 참여하는 것에 동의한다. 본 문서에 작성한 내용은 모두 사실에 기반한다. 정부에서 발급한
증명서와 본 문서에 작성된 이름은 모두 동일해야 하며 철자 확인은 본인의 책임이다. 항공사 안내와 비행기 티켓에 명시된 대로 지정된 여행 기간 내에 검사를 받는 것은 본인의
책임이다. PCR검사비 지원 프로그램을 통한 검사 및 결과지 수령에 소요되는 시간은 48 시간 내외지만 검사기관에 따라 시간이 지연될 수 있다. 본인(나)는 검사를 늦게
받거나 검사 결과가 불확실한 것으로 인해 발생할 수 있는 반응, 부상, 신체적 상해 또는 고통에 대해 괌정부관광청 및 검사 기관의 책임이 없다는 것에 동의한다. 괌정부관광청
및 PCR 검사비 지원 프로그램에 참여하는 의료기관은 항공 변경 수수료, 재예약 수수료, 취소 수수료
및/또는 항공편 예약, 숙박, 옵션 투어, 예약 또는 임금 손실과 같은 기타 여행 관련 비용에 대해 재정적 책임을 지지않는다. 본인(나)는 American Medical
Center (의료기관)이 여행 기간 동안 실시하는 PCR 검사 결과,
여권 사본, 운전면허증 또는 출생 증명서, 출입국 증명 사본이 포함된 개인 정보를 열람하는 데에 동의한다."
"在下方簽名，我 (病人) 同意參加關島觀光局為回返旅客提供的免 費PCR檢測項目。我所提供的訊息都是真實且正確的。 我明白我的責任是驗證我的名字是否與我的政府簽
發身分證件相符。我明白我有責任在航空公司和機票上指定的窗口內進行檢測。我理解這個項目的整備時 間是48 小時內，但可能會依實驗室的不同而有所延誤。我理解關島觀光局，及參與的醫療院所，對於測試
American Medical Center (診所) 公布我與旅遊PCR 檢測相關的病人訊息，包括我的測試結果，我的護照，駕照或出生證明的複印件，我的到達和離開日的確認複印件。"
Your initial confirms that you consent to COVID-19 testing, and, if you have any of the symptoms, you
will isolate yourself from any other people until you receive a negative test result.