COVID-19 Antigen Test Consent Form
The following information is required for tests to be billed through insurance. Failure to complete will result in further questioning or charges for the test and administration of the test.
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
What is the name of your primary care provider?
I identify my race as
Medications (n/a if none)
*
Allergies (n/a if none)
*
Upload a picture of the front of your primary medical insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload a picture of the back of your primary medical insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
What is your relationship to the cardholder?
Please Select
Cardholder
Spouse
Dependent
Cardholder name
Cardholder date of birth
/
Month
/
Day
Year
Date
Cardholder gender
COVID Screening
In the past 14 days, have you been in contact with anyone that has known infection or tested positive for
COVID-19
Flu
Other
When did your symptoms start?
*
-
Month
-
Day
Year
Date
Have you had a fever > 100.3 degrees F since symptoms started?
*
Please Select
Yes
No
Unsure
Please Indicate any of the symptoms you are experiencing
*
Runny Nose
Nasal Congestion
Sinus Pain/Pressure
Cough
Wheezing
Shortness of Breath
Nausea
Vomiting
Diarrhea
Muscle Pain
Body Aches
Loss of Taste
Loss of Smell
Dizziness
Headache
Other
REALD
The Oregon Department of Human Services would like to better serve you as an individual. They request the following information to better address health and service differences. The following questions related to REALD are optional to answer. Any blank answer will be considered as a declination to answer. Declined answers may be subject to further questioning in the future.
1. How do you identify your race, ethnicity, tribal affiliation, country of origin, or ancestry?
2. Which of the following describes your racial or ethnic identity?
Select all that apply
Hispanic and Latino/a/zX
Central American
Mexican
South American
Other Hispanic or Latino/a/x
Native Hawaiian and Pacific Islander
Chamoru (Chamorro)
Marshallese
Communities of the Micronesian Region
Native Hawaiian
Samoan
Other Pacific Islander
White
Eastern European
Slavic
Western European
Other White
American Indian and Alaska Native
American Indian
Alaska Native
Canadian Inuit, Metis, or First Nation
Indigenous Mexican, Central American, or South American
Black and African American
African American
Afro-Carribean
Ethiopian
Somali
Other African (Black)
Other Black
Middle Eastern/North African
Middle Eastern
North African
Asian
Asian Indian
Cambodian
Chinese
Communities of Myanmar
Filipino/a
Hmong
Japanese
Korean
Laotian
South Asian
Vietnamese
Other Asian
Other race or ethnic identity
If you checked more than one racial or ethnic identity, please specify your primary identity, biracial/multiracial, don't know, or don't want to answer
4a. What language or languages do you use at home?
Skip to question 7 if you indicated English only
4b. In what language do you want us to communicate in person, on the phone, or virtually with you?
4c. In what language do you want us to write to you?
5a. Do you need or want an interpreter for us to communicate with you?
Yes
No
Don't know
Don't want to answer
5b. If you need or want an interpreter, what type of interpreter is preferred?
Spoken language interpreter
Deaf Interpreter for DeafBlind, additional barriers, or both
American Sign Language interpreter
Contact sign language (PSE) interpreter
Other (please list)
6. How well do you speak English?
Very Well
Well
Not Well
Not at all
Don't know
Don't want to answer
Questions 7-15
Your answers will help us find healh and service differences among people with and without functional difficulties. Your answers are confidential. (Please write "Don't Know" if you don't know when you acquired this condition)
7. Are you deaf or do you have serious difficulty hearing?
Yes
No
Don't know
Don't want to answer
If yes, at what age did this condition begin?
8. Are you blind or do you have serious difficulty seeing, even when wearing glasses?
Yes
No
Don't know
Don't want to answer
If yes, at what age did this condition begin?
9. Do you have serious difficulty walking or climbing stairs?
Yes
No
Don't know
Don't want to answer
If yes, at what age did this condition begin?
10. Because of physical, mental or emotional condition, do you have serious difficulty concentrating, remembering or making decisions?
Yes
No
Don't know
Don't want to answer
If yes, at what age did this condition begin?
11. Do you have difficulty dressing or bathing?
Yes
No
Don't know
Don't want to answer
If yes, at what age did this condition begin?
12. Do you have serious difficulty learning how to do things most people your age can learn?
Yes
No
Don't know
Don't want to answer
If yes, at what age did this condition begin?
13. Using your usual (customary) language, do you have serious difficulty communicating (for example understanding or being understood by others)?
Yes
No
Don't know
Don't want to answer
If yes, at what age did this condition begin?
14. Because of a physical, mental or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?
Yes
No
Don't know
Don't want to answer
If yes, at what age did this condition begin?
15. Do you have serious difficulty with the following: mood, intense feelings, controlling your behavior, or experiencing delusions or hallucinations?
Yes
No
Don't know
Type option 4
If yes, at what age did this condition begin?
REALD Questions End
What is the make/model/color of you car?
Consent to Test
By signing your name below, you consent to medical care and treatment as ordered by a provider, while such care is provided through Grants Pass Pharmacy on an office visit basis. This consent includes all medical services rendered under the general or specific instructions of the provider as deemed reasonable and necessary. At the discretion of Grants Pass Pharmacy pharmacists and as needed by law, information regarding this test may be shared with other healthcare providers, third party/insurance, appropriate public health authorities, etc. without my individual consent.
Signature. If under the age of 15, parent/guardian must sign.
*
Name of parent/guardian if patient is under the age of 15.
First Name
Last Name
Submit
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