COVID-19 Testing Registration & Consent Form
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you currently smoke or use tobacco products?
*
Yes
No
In the past 14 days, have you had close contact (< 6 feet for >15 minutes) with anyone with the following? (Check all that apply)
*
Person with COVID-19 who has symptoms (listed above) that had a positive test OR was diagnosis based on clinical symptoms
Person who has tested positive for COVID-19 but has not had any symptoms
No, I have not been exposed and/or have symptoms. I’m testing for travel or work related purposes
No, I have not been exposed and/or have symptoms. I’m testing for medical related purposes
Please choose the desired date of your COVID test
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-
Month
-
Day
Year
Date
Please select the desired time of your COVID test
*
9:00
9:30
10:00
10:30
11:00
11:30
1:00
1:30
2:00
2:30
3:00
3:30
I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.
*
I understand
Signature
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