COVID INTAKE FORM

2140 W FLAGLER ST SUITE 211 MIAMI FL 33135

P: 305-644-4022 F: 305-644-4028
APPOINTMENTS MUST BE CONFIRM BY CALL TO 305-644-4022

Citas deben ser confirmadas, llamar al 305-644-4022
Testee's Full Name*

First Name / Primer NombreLast Name / Apellido
Date of Birth*

MonthDayYear
Fecha de Nacimiento
Passport Number (If Needed On Results)
Numero de Pasaporte (si es necesario en resultados)
U.S. Address (Hotel Address If Applicable)*

Direccion (Direccion De Hotel Si Es En Hotel)

Suite

City / CiudadState / Estado

Zip Code / Postal
Email*
example@example.com
U.S. Phone Number (if not, just put 0)*
Numero de Telefono U.S.
UPLOAD PHOTO ID (Driver's License, Passport, Etc.)*

SUBIR FOTO DE IDENTIFICACION! (PASAPORTE, LICENCIA, ETC.)
Cancelof

COVID-19 INTAKE FORM
REASON FOR TESTING TODAY (CHECK ALL THAT APPLY)*

Experiencing SymptomsPossible ExposureTraveling PurposesMedical ProcedureOther
Have you tested positive for COVID-19 in the past?*

YesNo
Have you been in contact with a positive case?*

YesNo

CONSENT FOR PROCEDURE

*** If for minor, parent or guardian must sign!
I Full Name* understand that this procedure will be performed by PEACE OF MIND REHAB, INC.
I Full Name* , give consent to PEACE OF MIND REHAB, INC to perform the COVID test.
Attention Patients

Please keep in mind that there is a possibility of having to have your specimens reran if the result does not meet the criteria for the lab to release.
Testee's Initials*
Iniciales del Paciente
Testee's Signature *

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How did you hear about us?*

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2140 W FLAGLER ST SUITE 211 MIAMI FL 33135