Coronavirus Intake form

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Name* This field is required.
First Name
Last Name
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SITE LOCATION * This field is required.PLEASE CHOOSE THE CURRENT SITE LOCATION
ST JOHNS CATHEDRAL- NYC
OTHER
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DATE OF TEST
Date
Month
Day
Year
4
PLEASE ANSWER ALL QUESTIONS
Yes
No
Have you tested positive for COVID-19 in the last 7 days?
Are you waiting for a COVID-19 test or the results?
Do you have a high temperature or fever?
Do you have a new or continuous cough?
Have you experienced a loss of Smell or taste?
Do you or anyone in your household have symptoms of COVD-19?
Have you been in contact with anyone in the last 14 days who is experiencing COVID-19 symptoms?
I DO NOT HAVE ANY SYMPTOMS- NOT LISTED
Have you tested positive for COVID-19 in the last 7 days?
Are you waiting for a COVID-19 test or the results?
Do you have a high temperature or fever?
Do you have a new or continuous cough?
Have you experienced a loss of Smell or taste?
Do you or anyone in your household have symptoms of COVD-19?
Have you been in contact with anyone in the last 14 days who is experiencing COVID-19 symptoms?
I DO NOT HAVE ANY SYMPTOMS- NOT LISTED
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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ARE YOU A HEALTHCARE WORKER
YESNO
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DO YOU HAVE A RUNNY NOSE
YESNO
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DO YOU HAVE A SORE THROAT OR COUGH
YESNO
8
ARE YOU EXPERIENCING NAUSEA OR VOMITING
YESNO
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Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
YESNO
10
HAVE YOU BEEN EXPOSED TO ANOTHER PATIENT
YESNO
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WHAT DAY DID YOUR SYMTOMS START
Date
Year
Month
Day
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PLEASE CHOOSE THE TESTSPLEASE BE AWARE THAT THE TIME FRAME RESULTS WILL COME IN VARIES. WE ARE AT 1-5 DAYS NOT INCLUDING WEEKENDS. PLEASE DO NOT CALL THE OFFICE ASKING FOR RESULTS UNTIL IT HAS BEEN 5 DAYS FROM THE DAY YOU TESTED.
RAPID AG- MOST ACCURATE IF YOU ARE SYMPTOMATIC- RESULTS WITHIN 8 HOURS
LAB BASED PCR/NAA- 1-5 DAYS NOT INCLUDING SUNDAYS
EXPEDITED PCR- ABBOTT ID NOW
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Patient Consent To The Use of Telemedicine/ communications of Results
Clear
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Terms and Conditions* This field is required.
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Terms and Conditions* This field is required.QR code WITH PRIVACY NOTICES
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SignaturePlease carefully read and sign the following Informed Consent:I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab or blood draw, as ordered by an authorized medical provider or public health official. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law. I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others. I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.
Clear
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UPLOAD INSURANCE AND ID- PLEASE DO THIS SO YOU DO NOT HAVE TO WAIT IN LINE. THIS WILL EXPEDITE THE PROCESS* This field is required.
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