COVID-19 Form

COVID-19 Testing Form
Brownsville Kiddie Health Center

95 E. Price Rd. Bldg. F Brownsville, TX 78521
Please fill out form for the COVID-19 Antigen nasal swab test.
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Have you been in contact with a COVID-19 positive case? *

Yes No
If YES, When did you come in contact with a COVID-19 patient?

Month Day Year
Date
Are you having any symptoms of COVID-19 like fever, cough, shortness of breath, sore throat, loss of taste or smell etc. *

Yes No
You understand that you should isolate yourself for 10 days from the time of first exposure. *

Yes
What does it mean if I test negative for COVID-19? A negative test result means that the virus that causes COVID-19 was not found in your sample. A negative test result for a sample collected while a person has symptoms usually means that COVID-19 did not cause your recent illness. However, it is possible for this test to give a negative result that is incorrect (false negative) in some people with COVID-19.This means that you could possibly still have COVID-19 even though the test result is negative. If this is the case, you should contact your healthcare provider and they will consider the test result together with your symptoms and possible exposures in deciding how to care for you. If you are symptomatic, a NEGATIVE result does NOT release you from quarantine or isolation. *

Agree
The fee for testing is $80, payment is required at the time of service and is not refundable. *

Agree
I understand that there is no doctor patient-relationship by filling out this form and having the lab test performed. I also understand that it is my responsibility to contact my doctor regarding the results of this test. *

Agree
I have read and agree to the Patient Fact Sheet and will consult my doctor for the result. *

Agree
Fact Sheet English

Fact Sheet Spanish
Signature *

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COVID-19 Testing Form

Brownsville Kiddie Health Center

Please fill out form for the COVID-19 Antigen nasal swab test.