COVID Testing Appointment Form

COVID Testing Appointment Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender assigned at Birth*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Mobile Phone Number*

Area CodePhone Number
Are you currently experiencing any symptoms?*

High feverCoughDifficuly breathingBody achesNasal congestionRunny noseSore throatPersistent pain or pressure in the chestDiarrheaNoneOther
What test are you registering for?*
You have chosen the Abbott BinaxNow (Rapid Antigen) test. This test is only meant for symptomatic individuals. Please note if you are currently asymptomatic or are asymptomatic upon arrival, you will be directed to complete a send out PCR and not qualify for an antigen test at this time. The send out PCR will result within 3-5 days.
Get Your Appointment*
By signing below I certify:

1.    That I have read or have had this consent read to me.

2.    That I was given an opportunity to ask questions.

3.    That all my questions were answered to my satisfaction, and

4.    That I understand this consent and accept its terms and conditions.

Notice of Privacy Practices: I understand I have a right to review LaSalle County Health Department’s Notice of Privacy Practices prior to signing this document. LaSalle County Health Department’s Notice of Privacy Practices has been offered to me. The Notice of Privacy Practices described the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of LaSalle County Health Department. This notice of Privacy Practices also describes my rights and LaSalle County Health Department’s duties with respect to my protected health information.
Signature*

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