Covid-19 Testing Consent Form






Questionaire

Lordsburg: Hidalgo County COVID-19 Community Clinic
Address: 109 Poplar Street Lordsburg, NM 88045

Silver City: Grant County COVID-19 Community Clinic
Address: 1304 E 32nd Street, Silver City, NM 88061


I hereby give Hidalgo Medical Services (HMS) consent to conduct COVID-19 testing. The test detects if you have SARS-CoV-2 (the virus that causes COVID-19) at the time of the test only. It does not test for immunity or if you had the virus in the past. I authorize HMS to contact me via phone at the number listed above for test results. I understand that my results will be reported to the New Mexico Department of Health for tracking and contact tracing purposes. I authorize HMS to release all information necessary to secure payment of benefits from my insurance company.

If my test results come back positive, my Primary Care Provider (PCP) will be notified.


I certify this information is correct.