PCHD COVID-19 Registration Form

1
Which of the following best describes the reason(s) you are seeking COVID-19 testing?* This field is required.Select any and all that apply.
Ongoing or recent illness that I suspect could be COVID-19.
Potential exposure to COVID-19 within the last 14 days.
Return to Work
Physician Order
Personal Awareness
Other
2
In the past 14 days, have you been in "close contact" with somebody who has been diagnosed with, or presumed by a healthcare provider to have, COVID-19?* This field is required.For the purposes of COVID-19 screening, "close contact" is defined by the Centers for Disease Control and Prevention as "having been within 6 feet of an infected person for at least 15 minutes starting from 2 days before illness onset (or, for [those without symptoms], 2 days prior to positive specimen collection) until the time the patient is isolated."
YESNO
3
Approximately how many days has it been since you were last in "close contact" with somebody who has been diagnosed with, or presumed by a healthcare provider to have, COVID-19?Please enter a number between 0 and 14.
4
Are you currently experiencing any of the following signs or symptoms?* This field is required.A fever (100.4º or higher), new/worsening cough, new/worsening shortness of breath, new/worsening muscle or body aches, new/worsening fatigue, new/abnormal sore throat, new/worsening/abnormal congestion or runny nose, new/worsening/abnormal diarrhea, new loss of taste, new loss of smell, or nausea/vomiting.
YESNO
5
Which of the following signs or symptoms are you currently experiencing?* This field is required.Please select all that apply.
Fever (100.4ºF or Higher)
New/Worsening Cough
New/Worsening Shortness of Breath
New/Worsening Muscle or Body Aches
New/Worsening Fatigue
New/Abnormal Sore Throat
New/Worsening/Abnormal Congestion or Runny Nose
New/Worsening/Abnormal Diarrhea
Nausea or Vomiting
New Loss of Taste
New Loss of Smell
6
COVID-19 Testing Appointment* This field is required.
7
Appointment Date
Date
Month
Day
Year
8
Your Name* This field is required.Please provide your FULL LEGAL NAME, as it is listed on a government-issued identification card.
First Name
Middle Name
Last Name
Suffix
9
Date of Birth* This field is required.
Date of Birth (MM/DD/YYYY)
Month
Day
Year
10
Social Security Number (Last 4 Only)Although not required, providing the last four digits of your social security number can prevent issues with billing insurance providers and/or reporting test results in an accurate and timely manner. We do strongly encourage that patients provide their social security number to prevent such issues. Please note that this form is compliant with all patient privacy regulations, as is required by HIPAA and the HITECH Act.
11
Gender* This field is required.
Male
Female
Other
12
Race* This field is required.Please mark all that apply.
African American/Black
American Indian/Alaskan Native
Asian
Caucasian/White
Unknown
I do not wish to provide this information at this time.
13
Ethnicity* This field is required.
Hispanic or Latino
Not Hispanic or Latino
Unknown
I do not wish to provide this information at this time.
14
Email AddressPlease provide a valid email address. By providing your email address, the contracted lab may provide you with access to your test results via a patient portal and you are provided with the opportunity to sign up for notifications for when vaccine is available to the general public in your local area.
Please enter your primary email address.
15
Would you like to receive notification by email when a COVID-19 vaccination becomes available to the general public?
YESNO
16
Physical Address* This field is required.Please provide the physical address of your PRIMARY residence. PLEASE DO NOT UTILIZE A POST OFFICE BOX, AS YOU WILL BE ASKED TO PROVIDE A VALID 911 ADDRESS AT THE TIME OF TESTING.
Physical/Street Address
Apartment Number/Lot Number/Suite Number
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
17
Which of the following best describes the type of housing in which you live?* This field is required.
Single Family Home (House or Mobile Home)
Apartment or Condo
Shelter
Group Home
Homeless
Nursing Home
Other
18
Other Type of HousingTo help public health officials understand the type of housing in which you reside, please enter a short description (no more than 2-3 words) of your housing type.
19
Is your mailing address the same as the physical address you just provided?* This field is required.
Yes
No
20
Mailing AddressPlease provide your mailing address, if different than your physical address.
Mailing Address
Mailing Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
21
Are currently employed?* This field is required.
YESNO
22
Are you employed by any of the following?Please select any and all that apply.
Healthcare Facility (Hospital, Nursng Home, Assisted Living Facility, Physicians Office)
Emergency Response Agency (911 Dispatch Center, EMS Agency, Fire Department, Law Enforcement Agency)
Grocery Store
Childcare Facility
Correctional Facility
Food Company (Manufacturer or Distributor)
Educational Institution
Other Critical Infrastructure
I am not employed by an organization that meets any of the above descriptions.
23
Other Critical Infrastructure Employer TypePlease provide a brief description (1-3 words) of your employer type so that public health officials can better understand your type of employment.
24
Primary Phone Number* This field is required.Please provide a valid telephone number where you can be reached if your test results indicate the presence of the COVID-19 virus.
25
Secondary Phone Number (If Applicable)Simply click "Next" if you do not have a secondary phone number or if you do not wish to provide one at this time.
26
Would you like to receive an influenza ("flu") vaccination at the same time as COVID-19 testing?* This field is required.NOTE: COVID-19 vaccinations are NOT currently available.
Yes, I would like to receive an influenza vaccination at the time of my COVID-19 testing.
No, I only wish to be tested for COVID-19.
27
Is the person being registered for vaccination currently sick or otherwise ill?
YESNO
28
Please explain the signs or symptoms that the registrant is currently experiencing.
Huge
Large
Normal
Small
Ok
Ok
29
Does the person being registered for vaccination have an allergy to eggs, medications, food, latex or to a component of the vaccine?
YESNO
30
Please provide a list of the registrant's allergies.
Huge
Large
Normal
Small
Ok
Ok
31
Has the person being registered for vaccination ever had a serious reaction after receiving a vaccination?
YESNO
32
Has the person being registered for vaccination ever been diagnosed with Guillain-Barré Syndrome (GBS) by a physician?
YESNO
33
Are you pregnant or is there a chance you could become pregnant?
YESNO
34
Are you currently covered by medical insurance?Examples of medical insurance providers include Medicare, Medicaid, Aetna, PEIA, etc.
YESNO
35
Primary Insurance ProviderPlease enter your the information below from the insurance card provided to you by your primary medical insurance provider. If you do not have your policy number this information readily available, please be prepared to provide it at the time of vaccination. Please bring a copy of your medical insurance card with you at the time of vaccination.
Insurance Provider Name (ex. Medicare, Medicaid, Aetna, PEIA, etc.)
Subscriber ID Number
Group Number (If Applicable)
Self
Spouse
Child
Other
Relationship of Policy Holder
Name of Policy Holder
36
Submit A Photo of Your Primary Insurance Card?To speed up the registration and immunization process, you can take a picture of the front of your insurance card. If you wish to submit a photo of your insurance card, please click the button below to take a picture of the FRONT of your insurance card.
37
Does your insurance card also contain information on the back, such as phone numbers or addresses?
YESNO
38
Lets take a picture of the back of your card!Please click the button below to take a picture of the BACK of your insurance card.
39
Would you like to add a secondary insurance provider?
YESNO
40
Secondary Insurance ProviderPlease enter your the information below from the insurance card provided to you by your primary medical insurance provider. If you do not have your policy number this information readily available, please be prepared to provide it at the time of vaccination. Please bring a copy of your medical insurance card with you at the time of vaccination.
Insurance Provider Name (ex. Medicare, Medicaid, Aetna, PEIA, etc.)
Subscriber ID Number
Group Number (If Applicable)
Self
Spouse
Child
Other
Relationship of Policy Holder
Name of Policy Holder
41
Submit A Photo of Your Secondary Insurance Card?To speed up the registration and immunization process, you can take a picture of the front of your insurance card. If you wish to submit a photo of your insurance card, please click the button below to take a picture of the FRONT of your insurance card.
42
Does your insurance card also contain information on the back, such as phone numbers or addresses?
YESNO
43
Lets take a picture of the back of your card!Please click the button below to take a picture of the BACK of your insurance card.
44
Registrant ID Number
45
PLEASE CLICK THE SUBMIT BUTTON BELOW TO FINALIZE YOUR APPOINTMENT REQUEST AND SUBMIT YOUR DATA TO THE PUTNAM COUNTY HEALTH DEPARTMENT.
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