COVID-19 TESTING PATIENT SCREENING AND CONSENT FORM

THIS FORM IS FOR TESTING ONLY. THIS IS NOT FOR THE VACCINE. PLEASE DO NOT FILL THIS OUT UNLESS YOU ARE GETTING A COVID TEST
Rapid Specimen #
Rapid Results
PCR Results
Results Reported to ECLRS
Results given to patient
First Name *
Last Name *
Date of Birth *

Month Day Year
Date
Type of test being performed *

PCR only ($35 collection fee) Rapid only ($130 collection/processing fee) PCR and Rapid ($165 collection/processing fee)
Address
City *
State *
Zip code *
Cell Phone *
Gender *
Email *
example@example.com
Allergies
Alternate Address you may be staying at while in NY

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
If female, are you currently pregnant or breastfeeding? *

Not female Not pregnant Pregnant Breastfeeding
Primary Care Provider Name
Primary Care Provider Phone or Location
Race (check all that apply) *

American Indian or Alaska Native Native Hawaiian or Pacific Isalnder Asian White/Caucasian Black/African American Other
Ethnicity *

Hispanic or Latino Not Hispanic or Latino
Have you had direct exposure with anyone that has tested positive within the last 14 days? *

Yes No
Do you have any of the following symptoms *

Fever or chills New loss of taste or smell Cough or Shortness of breath Sore throat/Hoarseness Fatigue Congestion or runny nose Muscle or body aches Nausea, vomiting or Diarrhea Headache No Symptoms
Onset of symptoms: (MM/DD/YY)
Is this your first test for COVID 19? *

Yes No
Have you ever tested positive for COVID 19?

Yes No
Date of Postitive Test

Month Day Year
Date
Do you live alone? *
Occupation, Job title, Student *

Retired/Unemployed Student Works from home only Other
Employer/School Name
Work/ School Address

Employer/School Address

Street Address Line 2

Employer/School City Employer/School State
Employer/School Zip
Employer or School Phone
Primary Insurance
Secondary Insurance
CREDIT CARD #
Expiration (MM/DD)
Security code
Name on card
Billing zip code
Total charged to pt
Signature

Clear
Date

Month Day Year
Date
Symptoms of Coronavirus accessd from CDC website on September 16,2020, available at https://www.cdc.gov/coronavirs/2019-ncov/symptoms-testing/symptoms.html
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