COVID-19 Testing Registration and Consent Form

Full Name *

First Name Last Name

Date of Birth *

Gender *

Male Female Other

Phone Number *

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Primary Insurance *

Specific Plan Name

Policy Number *

Group Number *

Insurance Subscriber Name (Insurance Policy Holder. Type "Self if you are the Policy Holder *

Insurance Subscriber Address (Insurance Policy Holder. Type "Self if you are the Policy Holder *

Insurance Subscriber Date of Birth (Insurance Policy Holder. Type "Self if you are the Policy Holder *

Insurance Subscriber Phone Number (Insurance Policy Holder. Type "Self if you are the Policy Holder *

Upload Government Issued Identification and Insurance Card (i.e Take a picture of both and upload. If you do not have Insurance, just upload a picture of just your ID) *

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Preferred Local Pharmacy (please provide name of pharmacy, address, and phone number) *

Appointment

Do you have a history of, or currently have, any of the following health conditions? (Check all that apply) *

PAST MEDICAL HISTORY Do you have any other chronic medical conditions (in addition to those above)? *

Yes No

If yes, what medical conditions do you have?

Please list any chronic medical conditions you have

Do you have any medication allergies? *

Yes No

Please list any medication allergies

Please list any drug allergies you may have

Are you currently taking any medication? *

Yes No

List of current medications

Please list any prescription or OTC medications or supplements you take regularly

Do you currently smoke or use tobacco products? *

Yes No

In the past 14 days have any? (Check all that apply) *

In the past 14 days, have you had close contact (< 6 feet for >15 minutes) with anyone with the following? (Check all that apply)

Person with COVID-19 who has symptoms (listed above) that had a positive test OR was diagnosis based on clinical symptoms Person who has tested positive for COVID-19 but has not had any symptoms

Signature *

Clear

COVID-19 Testing Registration

Exposure