Schedule a Rapid COVID-19 Test

COVID-19 Test Appointment & Consent Form
Which testing option would you like to receive?*
Select your COVID-19 Testing Appointment Time*
Submitter Name
Facility Name
Facility Address
Facility City
Facility State
Facility Zip Code
Facility County
Facility Phone
Facility CLIA Number
Pharmacist Name (ordered the test)
Pharmacist NPI
What is the patient's affiliation to the facility

ResidentStaffPatientStudentClientInmate
Specimen Type

Nasal
Test Name

BD Veritor System for Rapid Detection of SARS-CoV-2
Patient Name*

First name Middle name Last name
Date of birth (MM/DD/YYYY)*

MonthDay Year
Date
Age*
Address*

Street Address (and unit/apt # if applicable)

Street Address Line 2

City State / Province

Zip code
State*
You may choose a different option if your State is different
Phone Number*
Sex at birth*

FemaleMaleNeither/OtherUnknown
Select the most appropriate status below regarding pregnancy*

PregnantPostpartumUnknownNeither pregnant nor postpartum
Race (select all that apply)*

UnknownAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhiteOther race (specify)
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoUnknown
Do you have any symptoms?*

YesNoUnknown
List your symptoms (if applicable)

Fever or chillsCoughShortness of breath or difficulty breathingFatigueMuscle or body achesHeadacheNew loss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrhea
Email Address *
example@example.com
Signature*

Clear
Date*
Should be Empty:

COVID-19 Test Appointment & Consent Form