COVID Testing Questionnaire

COVID Testing Questionnaire

If you have made an appointment to be tested for Coronavirus (COVID-19) at UITCT, please fill out the following form and provide us with as much information as possible about your location, work, symptoms, and who you have been in contact with.
Contact Information
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
When is the best time to contact you?

MorningAfternoonEvening
May we leave a voicemail message at this number?

YesNo

COVID-19 Symptom Assessment

Please note if you have experienced any of the following symptoms.
When did you first start to feel symptomatic?

MonthDayYear
Date
Please list all symptoms you are experiencing.
Are you experiencing any symptoms other than those listed above?
Contacts
Emergency Contact Information
Please list ALL people you have had contact with in the past 14 days?
What businesses have you visited in the last 14 days?
Have you recently been in another public and/or crowded location?

YesNo
Please list any other public areas or events.

Consent
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

I authorize the UITCT COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab, as ordered by an authorized medical provider or public health official.

I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.

I acknowledge that a positive test result is an indication that I must continue to self-isolate in an effort to avoid infecting others.

If a positive test result is received UITCT has my consent to contact persons who have been in close contact and may have been exposed to COVID-19.

I understand that, as with any medical test, there is the potential for false positive or false negative test results can occur.

Please sign below that you have read and consented to these statements.
Signature

Clear
UITCT will not, under any circumstances, share your personal information with other individuals or organizations without your permission, including public organizations, corporations, or individuals, except when applicable by law.
Should be Empty:

Contact Information