Coronavirus Testing Request for The Uninsured Patient.
Complete this form before presenting to the clinic
CLINIC ADDRESS
11901 Shadow creek pkwy#111, Pearland TX 77584
Personal Information
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Gender
Male
Female
SSN or DL number
*
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Attach ID card or Driver License
*
Upload ID
Cancel
of
Health and Medical History
Please check all that apply
Anemia
Asthma
Arthritis
Cancer
Gout
Diabetes
Epilepsy Seizures
Heart Disease
Heart Attack
Rheumatic Fever
High Blood Pressure
Digestive Problems
Ulcerative Colitis
Hepatitis
Kidney Disease
Liver Dİsease
Thyroid Problems
Tuberculosis
Venereal Disease
Neurological Disorders
Bleeding Dİsorders
Lung Disease (Chronic Obstructive Pulmonary Disease)
Please list any allergies
Please list your current medications
Please list any surgeries and dates of each
Please type down family medical history
Do you smoke?
No
0-1 pack/day
1-2 packs/day
2+ packs/day
Do you have any risk of being pregnant?
Yes
No
COVID-19 Symptoms
Please check the symptoms that apply
High fever
Cough
Difficulty in breathing
Persistent pain or pressure in the chest
Body aches
Nasal congestion
Runny nose
Sore throat
Diarrhea
Any known exposure to COVID-19
*
Yes
No
This program is for ONLY UNINSURED PATIENTS through HRSA
*
I attest I do not not have any government funded or private insurance. I understand this is fraud if I do and use this program for testing.
I attest I have not already taken or done a government sponsored free testing.
Signature
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