Grapefruit Testing: Consent for COVID-19 Testing
Below, you will find a link to the consent form. To Opt-In for testing, (either for the first time or on a recurring basis) please complete the form and then sign it to submit it before the test date. NOTE: YOU MUST CLICK ON THE TERMS & CONDITIONS LINK AND READ IT THEN CHECK OFF THE BOX BEFORE YOU CAN PROCEED WITH THE FORM.
POD Code:
*
Select your testing location(s) choice. Note: PODs are Grapefruit’s mobile and temporary testing locations located within your community
*
In the school and community PODs
Community POD Only (no in-school testing)
Please sign below if you opt-in to the testing process
Contact/Demographic Information
The individual being tested is:
*
Staff
The person being tested is:
*
Self
Child/Dependent
What school are you affiliated with?
*
Please Select
Mays Landing Library
Name of the individual being tested
*
First Name
Last Name
Gender
*
Please Select
Male
Female
Non-Binary
Declined to specify
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Mobile Number
*
Please enter a valid phone number.
Address (mailing address)
*
Street Address (Please Use Line 2 for Apartment Number)
Street Address Line 2 (Please Use This Line For Apartment Number)
City
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
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Postal/Zip Code
Race
*
Please Select
White
Black/African-American
Native/Hawaiian/Other Pacific Islander
American Indian/Alaskan Native
Asian
2 or more races
Declined to specify
Ethnicity
*
Please Select
Hispanic
Not Hispanic
Unknown
Declined to Specify
Insurance Information
Name of Insurer (if you don't have insurance please type NONE)
*
Group ID Number
Name of Insured / Subscriber
*
First Name
Last Name
Insured Date of Birth
*
-
Month
-
Day
Year
Date
Insured/Member ID number
*
Past Medical History
Vaccination Status
*
Fully vaccinated against COVID-19
NOT fully vaccinated against COVID-19
Unvaccinated
Allergies to Medications?
*
Please Select
Yes
No
Taking Medications Currently?
*
Please Select
Yes
No
COMORBIDITIES - This patient has the following health conditions
*
Cancer
Kidney Disease
COPD
Immune Dysfunction
Significant Heart Disease (CHF, CAD, Cardiomyopathy)
Obesity (BMI >30)
Sickle Cell Disease
Diabetes Mellitus
None of the Above (CDC High-risk Health Conditions)
Declined to Specify
The patient is:
*
Please Select
Employed
A Student
Retired
Unemployed
Is there any additional past medical information that the testing team should be aware of? For example sensory issues, difficulty communicating, etc., (write NONE):
*
Please email us at security@grapefruithealth.net to request our data privacy best practices and data security processes.
__________
School District
Should be Empty: