School Covid Swab Form
Patient Information
First
*
Middle
Last
*
School grade
*
Please Select
Staff
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Date of Birth
*
/
Month
/
Day
Year
Date
Home Phone
Cell Phone
*
Day and time of testing
*
Please Select
Thursday, 1/28 11-6
Friday, 1/29 9-1
Sunday, 1/31 10-4
Did your insurance change? IF YES, PLEASE COMPLETE INSURANCE FIELDS
*
YES
NO
Insurance Information
Primary Insurance
Insurance Carrier
If UnitedHealthcare, please specify which plan.
Primary Subscriber's Name:
Date of Birth
/
Month
/
Day
Year
Date
Patients Relationship to Subscriber
Self
Spouse
Child
Parent
Other
Policy Number
Group Number
Secondary Insurance
Insurance Carrier:
If UnitedHealthcare, please specify which plan.
Primary Subscriber's Name
Date of Birth
/
Month
/
Day
Year
Date
Policy Number
Group Number
I allow Hebrew Academy of Long Beach to receive test results.
*
YES
NO
Rapid Reponse Medical Care
600
Franklin Ave. Franklin
Square, NY 11010
Submit
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