COVID-19 Testing Registration and Consent Form

COVID-19 Testing Registration
Full Name *

First Name Last Name
Date of Birth *

Month Day Year
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) *

Cancel of
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) *

Not applicable Cancer Kidney Disease COPD Immune System Dysfunction Congestive Heart Failure Coronary Artery Disease Heart Muscle Condition (Cardiomyopathy) Obesity (BMI > 30) Sickle Cell Disease Type 1 or Type 2 Diabetes Mellitus
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) *

Fever Chills Cough Shortness of Breath OR Difficulty Breathing Fatigue Muscle OR Body Aches Headache New Loss of Taste OR Smell Sore Throat Congestion OR Runny Nose Nausea OR Vomiting Diarrhea NO SYMPTOMS
Exposure
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
Should be Empty:

COVID-19 Testing Registration

Exposure