Consent & Acknowledgement for Covid-19 Testing

RELEASE, WAIVER, CONSENT, and ACKNOWLEDGEMENT FORM for COVID-19 TESTING and DISCLOSURE OF INFORMATION

(Please Read Carefully Before Signing at the end of the Document)

COVID-19 tests will not be administered by Penna’s Utilities Ltd. unless this form is completed and signed in advance of the scheduled test date and time.

1. I hereby understand that by booking a COVID-19 Rapid Antigen test with Penna’s Utilities Ltd. (“Penna’s Utilities”) for myself, or on behalf of a minor under the age of 18 or anyone else to whom I’m the legal Guardian for (“minor”), I consent to:
   1. Penna’s Utilities administering the COVID-19 Rapid Antigen test (“the COVID Test”) at 1420 Athabasca St. E, Moose Jaw, Saskatchewan (“the facility”);
   2. The collecting of personal information by Penna’s Utilities, as required for the COVID Test and the applicable health authority requiring such information (“the applicable health authority”); and
   3. Penna’s Utilities disclosing personal information and COVID Test results, as required by the applicable health authority, and any other disclosures as may be required. Personal information includes:
      1. first and last name of the individual being tested; and
      2. contact Information.
2. I hereby agree that I, or the minor being tested, will not enter the facility if experiencing any symptoms of COVID-19 or any of the following symptoms:
   • Fever
   • Cough
   • Tiredness
   • Loss of taste or smell
   • Sore throat
   • Runny nose
   • Body aches
   • Headache
   • Shortness of breath
   • Diarrhea
   • Nausea or vomiting
   • Chest Pain
3. I hereby acknowledge and understand that:
   1. Penna’s Utilities is required to disclose all COVID-19 test results and information required by the applicable health authority.
   2. Disclosure of information will include the results of the COVID Test result and personal information as prescribed in section one of this document.
   3. In the event that the COVID Test result comes back positive, I may be contacted by the applicable health authority.
   4. The COVID Test is not 100% accurate and may produce inaccurate results.
   5. Penna’s Utilities does not guarantee as to the accuracy of the COVID Test results.
   6. Though a false positive test result is uncommon, it is possible.
   7. In the event that I, or the minor tested, test positive for COVID-19, I, or the minor tested, will be subject to a second COVID-19 test for confirmation of results, which:
      1. Penna’s Utilities will not be administering; and
      2. will require for me to call 811 for arranging the second COVID-19 test.
   8. Though a false negative test result is uncommon, it is possible when the sample contains an insufficient sample for detection.
   9. There are several factors which may contribute to an infected person having an undetectable viral load at the time of testing, some of such factors are outside the control of Penna’s Utilities.
   10. It is my responsibility to verify COVID-19 testing requirements for travel, work, venues or any other environment where test results are so required.
   11. Penna’s Utilities will not be held accountable for any outcomes or costs associated with incorrect results from the COVID Test.
   12. This Release, Waiver, Consent and Acknowledgement form will be retained at and by Penna’s Utilities.
   13. The results from the COVID Test will be emailed to the email address provided at the beginning of this document by Penna’s Utilities in the form of a PDF document.
   14. In the event that I do not receive an email at the email address provided, I am to check the junk/spam folder of that email address.
   15. Penna’s Utilities will take all necessary steps to email the COVID Test results as soon as possible, but depending on the volume of tests being processed by Penna’s Utilities and other factors outside the control of Penna’s Utilities, the time in emailing such results may vary.
4. I hereby waive, release, and discharge Penna’s Utilities, and each of its affiliates, directors, officers, employees and agents of and from all claims, demands, damages, costs, expenses, actions, and causes of action, including injury, arising or to arise by way of attending to the facility for or in relation to the COVID Test, the COVID Test, or any related disclosures of information.
5. In executing this document, I am not relying upon any oral or written representation or statements of any nature or kind by Penna’s Utilities, or any of their affiliates, directors, officers, employees and agents.
6. I am executing this document with my own free will, in consideration of Penna’s Utilities providing the COVID Test and providing necessary disclosures to the applicable health authority.
7. I understand that Penna’s Utilities is compliant with PIPEDA (Personal Information Protection and Electronic Documents Act).

I acknowledge that I have read this document in its entirety and I understand and agree to the terms and conditions contained herein.