MEDMXP – MEDICAL SERVICE MALPENSA – info@medmxp.

it
STELVIO LAB | Viale Stelvio n. 125 | 21052 Busto Arsizio, VA | lab@vialestelvio.it | +39 0331 386028
Direttore di Laboratorio: Dr. Francesco Micali
Ragione sociale: CABE s.r.l. | Piazza Giovine Italia n. 3 | 20123 Milano, MI | C.F. e P.IVA 09163530968

INFORMATION AND CONSENT FOR THE PERFORMANCE OF THE RAPID ANTIGENIC NOSE-
PHARYNGEAL SWAB TO SEARCH FOR THE PRESENCE OF SARS-COV2 RNA (COVID-19)

The collection of the nose-pharyngeal swab is a procedure that consists in the collection of the superficial cells of the
mucosa of the posterior pharynx and nasopharynx, using a small stick in synthetic material capable of retaining
organic material. No fasting or preparation is required.
The sampling is performed in a few seconds and has minimal invasiveness, originating, at most, an imperceptible
annoyance in the touch point.
The antigenic rapid swab test is an immunochromatographic analysis for the qualitative determination of the
presence of the COVID-19 (Coronavirus) antigen by nasal swab. It is a purely diagnostic test to detect the presence
of the virus in a precise instant, very useful to identify a contagious subject and immediately subject him to self-
isolation to prevent the spread of the virus.
The presence of the virus in the respiratory mucous membranes is an index of replicative activity, therefore the
individual is highly contagious and must be subjected to quarantine, and to inform immediately his physician.
A negative result at the date of execution does not mean that the patient himself cannot be infectious in the following
days, especially if they were particularly exposed to risk of infection.
The swab report will always be available in the electronic health record by accessing the personal account.

For further information please visit the website: https://medicenter.vialestelvio.it/informativa/

Surname ______________________________________________________________________________________
Name_________________________________________________________________________________________
Date of birth______________________________ Place of birth __________________________________________
Fiscal code (Italian citizen only) or Passport n°_________________________________________________________
Resident in: ____________________________________________________________________________________
Address in Italy _________________________________________________________________________________
e-mail ______________________________________________________________________
Telephone number _____________________________________________

⃝ I AGREE ⃝ I DO NOT ALLOW

I authorize the processing of my personal data indicated above, according to the Italian Legislative Decree 196 (30th
June, 2003) and art. 13 GDPR (EU Regulation 2016/679), in particular: residence, telephone number and email
address. I acknowledge that, due to the Covid emergency, the timing of performance and reporting may be subject
to significant delays.

After having read the above information:

⃝ I AGREE ⃝ I DO NOT ALLOW

I declare that I am aware of the diagnostic limits related to the technique. I declare that I have read the information
on the processing of personal data.

Date _________________________ Signature _____________________________________

Sistema Sanitario