Covid 19 Testing Results
New Employee or Existing Employee
*
NEW EMPLOYEE (FIRST TEST @ ALL CARE)
EXISTING EMPLOYEE
FIRST NAME
*
MIDDLE NAME (BLANK IF NONE)
LAST NAME
*
ADDRESS
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CITY
*
STATE
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ZIP CODE
*
DATE OF BIRTH (MM/DD/YYYY)
*
PHONE NUMBER
*
SEX
*
FEMALE
MALE
PREGNANT?
*
PREGNANT
NOT PREGNANT
RACE (OPTIONAL)
Please Select
AMERICAN INDIAN OR ALASKA NATIVE
ASIAN
BLACK OR AFRICAN AMERICAN
NATIVE HAWAIIN OR OTHER PACIFIC ISLANDER
WHITE
OTHER
ETHNICITY (OPTIONAL)
Please Select
NOT HISPANIC OR LATINO
HISPANIC OR LATINO
TEST RESULT
*
NEGATIVE
POSITIVE
TEST USED
*
ABBOT BINAX NOW
BD VERITOR PLUS
OTHER
TEST PERFORMED BY
*
LIST ANY SYMPTOMS (BLANK IF NONE)
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