COVID-19 Testing Consent Form

1
Covid-19 Test Requested. We do not bill insurance:* This field is required.
2
Reason for Testing* This field is required.
Travel
Surgery
Back to School
Back to Work
3
Appointment Times Available* This field is required.
4
How would you like us to notify you of a negative test? A positive test will always receive a phone call.* This field is required.
Email
Phone Call
5
Phone Number* This field is required.
Please enter a valid phone number.
6
Email* This field is required.
example@example.com
7
Name* This field is required.
First Name
Last Name
8
Date of Birth* This field is required.
Date
Month
Day
Year
9
Patient Physical Address* This field is required.
10
Mother's Maiden Name* This field is required.
11
Emergency Contact Name* This field is required.
12
Phone Number of Emergency Contact* This field is required.
Please enter a valid phone number.
13
Relationship to Emergency Contact* This field is required.
Brother
Sister
Sibling
Mother
Parent
Guardian
Spouse
Grandparent
Child
Foster child
Stepchild
Care Giver
Other
14
I understand my test results will be disclosed to the county and state health entities as requried by law. I acknowledge that a positive test result is an indication that I may by required to isolate to avoid infecting others and identify close contacts to the Hillsborough County Health Department. I voluntarily consent to submit to a COVID test and have it analyzed. I also agree to allow the City/County Health Department to disclose my results to my employer if it is deemed necessarily to protect public safety.
15
Signature* This field is required.
Clear
Should be Empty: