nucleic-acid-test-request-form

1.  Please complete and sign by a guardian if the test requester is under 18 of age.  如受測者未滿18歲，必須由監護人填寫及簽署。
2. ^*Please select appropriate box.  ^*請在適當方格加上剔號。
3. ^#Please delete as appropriate  請删去不適用者

The test is intended for asymptotic individual COVID-19 testing and is not for the purpose of medical diagnosis or treatment. I am not having any of the following conditions. 本測試只適用於沒有新冠狀病毒病徵的人士，並非用於醫學診斷或治療。我確認我並沒有出現以下任何情況：

 ※ Sample needs to arrive in the lab within 24 hours after collection  樣本需要在採集後24小時內到達化驗所 ※

The accuracy of this test result is limited by sample handling manner, sample storage duration, condition of transportation, nucleic acid/cells contamination, nature of the viral sequences mutation and etc. Together with the limitation on the latest nucleic acid amplification technology, result conclusions with “False positive”, “False negative” and “Indeterminate” might be arisen. Therefore, it is advisable to take extra caution with the result interpretation due to the test limitations and potential errors. The overall detection limit of the test is 20 copies/µl and RNA copies below this detection limit cannot be guaranteed detectable. It is recommended to cross-reference with a confirmative approach for a definitive result. The sample will be used for test that ordered, after the test has been completed, all personal identification will be stripped and may be selected as the testing internal control purpose. The potential risk of injury during sample collection is outside the scope of our test service. Please seek medical advice if necessary.

I confirmed that I have read the above disclaimer and consent and I am fully informed about the nature, purpose, procedures and risks of this test. I understand and agree that this test serves for the above-mentioned purpose and acknowledge its limitations and potential errors. I undertake not to use the result of this test or any part thereof for any purpose other than the above-mentioned purpose shall release, indemnify and hold harmless the company, its employees, advisors, and agents against losses and damages arising out of anything connected with this test. I acknowledge and confirm that I have read and understood the (“PICS”) on page 2.
The English version of these terms and conditions shall prevail whenever there is a discrepancy between the English and Chinese versions.

此測試的準確性會因應樣本的處理方式、樣本儲存的時間、運送情況、核酸/細胞污染，病毒序列突變等原因而受到限制。再加上其他最新核酸擴增技術的限制，有可能出現「假陽性」、「假陰性」和「不確定」等結果。因為測試的限制和可能出現的誤差，在闡釋結果時應特別小心。測試的總檢出限為20拷貝/微升，低於此檢出限的RNA拷貝數將不能保證被檢測得到。建議同時參考其他確定性方法以助判斷最終診斷結果。您的樣本只會作您要求的測試項目及內部研究用途，所有個人身分證明待完成測試後將會銷毀或會被選作內部對照之用。樣本採集過程中潛在的傷害風險不在此次測試服務範圍內。如有必要，請尋求醫療意見。

本人確認已閱讀上述免責聲明及同意書，並充分了解本次測試的性質、目的、程序和風險。我理解並同意本次測試只用於上述目的，並知悉其局限性和潛在的誤差。我保證不使用這個測試的結果或其任何部分作任何上述目的以外的用途，並放棄任何因本次測試而引致的損失及傷害，向有關公司、公司所有人員、顧問、及代理人索償的權利。本人確認已閱讀並明白第二頁的<收集個人資料聲明>。本條款及細則的英文版本如與中文譯本之文義有任何歧異，一概以英文版本為準。