Wiley College Faculty & Staff COVID 19 Registration Form

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Health History Questionnaire & Consent To Treatment

Please fill in the form below
Name:*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
MaleFemale
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone Number:*

Area CodePhone Number
E-mail:
TYPE OF GOVERNMENT ISSUED ID
GOVERNMENT ISSUE ID NUMBER #
DRIVER LICENSE | STATE ID | PASSPORT

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If you are insuranced, please take front & back picture of your card only (no SSN). If uninsured, enter your Driver's License Number, Passport ID Number, and/or Social Security Number.
INSURANCE CARD (FRONT)

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INSURANCE CARD (BACK)

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COVID-19 EXPOSURE
Have you been exposed to anyone with COVID19 ?
Are you pregnant? (Female Only)
Sore ThroatCoughFever ChillsBody AchesShortness of BreathNauseaVomitingDiarrheaLoss of SmellLoss of TasteOther
Have you been previously tested positive for COVID19 ?
By signing this form, I understand the following:

The laws that protect privacy and the confidentiality of medical information also apply to telemedicine. I have the right to withhold or withdraw my consent to the use of telemedicine duirng my care at any time, without affecting my right to future care or treatment. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be in other areas, including out of state.

I acknowledge that I have been informed of my rights under the Health Information Protection and Portability Act (HIPAA), I understand that I may request copies of this information and rights any time.

I hereby authorize ARK LA Tex Covid Testing Solutions, to use HIPAA-compliant telecommunication for evaluating, testing and diagnosing my medical conditions. I do understand that this information will be shared with Wiley College.
Signature*

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Patient or Parent/Guardian's Name

First NameLast Name
Relationship:*
Date:

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

Health History Questionnaire & Consent To Treatment

COVID-19 EXPOSURE