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.Format: (000) 000-0000.
UPLOAD PHOTO ID (Driver's License, Passport, Etc.)

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

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
How did you hear about us?

Hotel (Write the hotel name)

2140 W FLAGLER ST SUITE 211 MIAMI FL 33135