COVID-19 Testing Consent

COVID-19 Testing Consent
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Reason for testing? Fill in the blank
If you are NOT a patient of The Logan Institute, we cannot give you any medical advice. Please contact your healthcare provider to assess how best to care for you based on your test result, along with your medical history and your symptoms
Signature

Clear
Date

Month Day Year
Date
Name of signee if parent or guardian

First Name Last Name
Should be Empty: