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  • Welcome to

    MyTexas Covid-19 Houston (MTCH)

    Health Questionnaire & Consent to Covid-19 Testing

    Form Homepage - Please complete all questions accurately to the best of your ability

  • MyTexas Covid-19 Houston

    So, You've Been Here Before? GREAT, Welcome Back!

    You have selected: 

    - Yes, I have been tested with MyTexas Covid-19 Houston before

    If this is in error, please use the back button and select another option on the homepage.

    If you have questions, find a MyTexas Covid-19 Houston (MTCH) Team Member and we will be happy to help.

     - PAGE 2 -

  • Returning Patient Verification

    Please completely answer all questions
  • We need your help to verify your identify:

    • Frist Name
    • Last Name
    • Date of Birth

     The information you enter needs to match what you input before.

     

    ENSURE THERE ARE NO SPACES AFTER YOUR NAME(s)

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  • MyTexas Covid-19 Houston 

    New Here?  Well, We Look Forward to Helping You!

    You have selected: 

    - No, this will be my first time testing with MyTexas Covid-19 Houston 

    (or your information didn't pull up and you selected: I tried pulling up my information but it was not found!)

    If you have questions, find a MyTexas Covid-19 Houston (MTCH) Team Member and we will be happy to help.

     - PAGE 3 -

  • New Patient Registration

    New Patient Registration - Please completely answer all questions
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  • All Adults being tested or Parent(s)/Guardian(s) of non-adults being tested must provide a photo of government identification

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  • If you are insured, 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.

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  • MyTexas Covid-19 Houston 

    Almost Finished!

    This is the Health Questionnaire & Submission Page

    If you have questions, find a MyTexas Covid-19 Houston (MTCH) Team Member and we will be happy to help.

  • Health Questionnaire & Consent To Testing

    New Patient Registration - Please completely answer all questions
  • COVID-19 EXPOSURE

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  • Submission

  • 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 MyTexas Covid-19 Houston, to use HIPAA-compliant telecommunication for evaluating, testing and diagnosing my medical conditions.

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  • The date and time listed below will be the timestamp for your submission (no need to change this, it cannot be edited).

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