COVID Vaccine Consent Form

COVID-19 RT-PCR Test Consent Form - Urbandale, Iowa

* Please fill out the required details below
Pharmacy Use Only
Collected: blanks
Read: blank
If you have remaining questions, please call us at (515) 276-3471.
Section I. Personal Information
Patient's Full Name: *

First Name Ml Last Name
Date of Birth: *

Month Day Year
Address: *

Street Address Line 2
Phone Number: *
Email Address: *
Gender: *

Male Female
Ethnicity: *

Hispanic or Latino Non Hispanic/Latino Unknown Prefer not to answer
Race: *

African American American Indian Asian Caucasian Native Hawaiian/Other Pacific Islander Prefer not to answer
Section II. Federal Government Mandated Questions

Please select Yes or No below: *

	Yes	No
1. Have you been given a COVID-19 vaccine in the past 9 months?
2. In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
3. Are you experiencing symptoms of COVID-19 such as: fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
4. If applicable, are you currently pregnant?
5. Do you have any medical conditions?
6. Are you employed in healthcare?
7. Do you live in a congregate care setting such as a nursing home or group home facility?

If you answered, YES to Question #3, when did you symptoms start? *
Day/Date of symptoms onset
Do you require a paper copy of your results to prove infection status for employer or travel? *
Please type YES or NO
Section III. Signature
By signing below:

- I attest to the accuracy of the above checklist.

- I acknowledge having had the opportunity to ask questions which were answered to my satisfaction.

- I acknowledge a negative result does not rule out the possibility of COVID-19 and should not be used as the sole basis for treatment or patient management decisions.

- I acknowledge that my test results will be reported to the Iowa Department of Public Health.
Signature of Person to Receive COVID-19 PCR Test (or Signature of Parent/Guardian if Patient is < 18 yo) *

Clear
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
Should be Empty:

COVID-19 RT-PCR Test Consent Form - Urbandale, Iowa