Woori Pharmacy COVID-19 Testing Registration Form

COVID-19 Testing Registration Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender: blanks*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Mobile Number*
Please enter a valid U.S. phone number.
Your contact info is only used for messages about this test.

By giving your mobile number, you agree to automated calls and text messages about this and follow-up visits, test results, healthcare, account and insurance, and agree to the Terms of Use and Privacy Policy. Standard message and data rates apply. Message frequency varies.
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoI don't want to answerI don't know
Race*

American Indian or Alaska NativeAsianBlack or African AmericanHispanicNative Hawaiian or Pacific IslanderWhite or CaucasianI don't want to answerI don't knowOther
Do you work in healthcare?*

YesNo
Are you a resident in a special setting where the risk of Covid-19 transmission may be high? This may include long-term care, correctional and detention facilities; homeless shelters; assisted-living facilities and group homes*

YesNo
Are you currently pregnant?*

YesNoPrefer not to answer
Are you experiencing any of the following symptoms?*

No symptomsFever over 100.4FFeeling feverishChillsCoughShortness of breathDifficulty breathingFatigueMuscle or body achesHeadacheNew loss of tasteNew loss of smellSore throatNasal congestionRunny noseNauseaVomitingDiarrhea
Date of symptom onset:

MonthDayYear
Date
Authorizations
I authorize Woori Pharmacy to:*

Send me a copy of my results via text message / email (optional)Send my personal health information electronically to other healthcare providers who have a treatment relationship with me or to my health plan for operations and care coordination as permitted by federal and state laws (optional)By checking here, I show that I understand the following statements: I'm consenting to test for COVID-19 —voluntarily—and can decline any tests at any time. My test results will be reported to the state health department where required by law. A copy of the Notice of Privacy Practices has been made available to me. I have reviewed the COVID-19 test fact sheet and Swabbing instructions. I certify that I am at least 18 years of age (if under the age of 18 but greater than 9 years old, a parent or guardian must sign for consent) and hereby give my consent to the staff at Woori Pharmacy to administer the test indicated. I have read the information sheet for my test and understand the benefits and risks of the test and choose to assume the risk. I fully release and discharge Woori Pharmacy and its affiliates, from liability for illness, injury, loss or damage which may result. I also consent to bill my medical and or prescription insurance for this service.
Signature of patient or legal guardian / representative*

Clear
Printed Name of patient or legal guardian / representative*
Relationship to patient, if signed by legal guardian / representative
Today's Date*

MonthDayYear
Date
Should be Empty:

COVID-19 Testing Registration Form

Authorizations