Return COVID-19 Testing Intake Form
Patient's Date of Birth
If you are filling out this form for the patient, please list your own name below:
Please list your relationship to the patient:
If you did not complete this information on your initial form or if insurance has changed.. please list your insurance if you have an insurance policy, even though we do not run through insurance, the lab requires we send the information. This is required even if your employer is paying. Thank you!
Primary Insurance Carrier Name (write N/A if none, same if unchanged from last form)
Insurance ID (write N/A if none, same if unchanged from last form)
Insurance Group Number
Secondary Insurance Carrier Name (if applicable)
Secondary Insurance ID
Secondary Group Number
Insurance Subscriber if Not Patient
Date of Birth of Subscriber if Not Patient
Drivers License/ID Number:
This is required, especially if you did not list an insurance. The Lab is requiring it for us to test you.
Have you had a known exposure to COVID-19? Check all that apply:
Yes- at home
Yes- at work
Are you currently experiencing any of the following symptoms? Check all that apply:
None of the below
Difficulty breathing or shortness of breath
Muscle or body aches
New loss of taste or smell
Congestion or runny nose
Nausea or vomiting
1. I understand that this COVID-19 swab is a service provided by Riviera ENT for diagnostic purposes only. 2. If am ill, I will seek the counsel of my physician, an urgent care or emergency department. If I am seriously ill, I will seek immediate emergency medical attention. 3. I will quarantine appropriately until results are available. 4. I understand that Riviera ENT physicians and staff are not responsible for the care of the patients undergoing testing. 5. Patients should contact the clinic at 805-327-6673 if they have not been given the results of testing within 5 business days of the test being collected. 6. Positive patients will be reported to the Santa Barbara County Health Department by the laboratory facility, and Riviera ENT may need to discuss these results with the Santa Barbara County Health Department or other healthcare providers.
I agree to the above
I consent to have my place of employment access the results of this testing
If yes, my place of employment is:
If any of your previous information from your initial form has changed, please list it below:
i.e. emergency contact, address, etc...
Signature of Patient/Guardian
Should be Empty:
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