Testing Center Intake Form
Have You Tested with Us Before?
*
Yes
No
Which Test do you Need?
*
Covid-19
Flu-A / Flu-B
RSV
Strep
Who is taking the test?
*
Adult
Minor
Do you require verification for work or travel?
Yes
No
Consent Adult
COVID-19, testing, contact tracing, and isolation of infected people supports the health and safety of the community. The purpose of this “ COVID-19 Testing Consent Form” is to consent to COVID-19 testing for the improved safety of the community. I authorize this testing unit to conduct collection and testing for COVID-19 through a nasal swab to screen for COVID-19 or at their discretion a cheek/under tongue swab test can be conducted to screen for COVID-19 I authorize this testing unit to share my test results with required government entities for the sole purposes of identifying others who may have been exposed. I understand test results will be shared with the County Public Health Department or to any other governmental entity the law requires. The release of any legally privileged and confidential records will be in accordance with applicable privacy protection laws, including the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA). I acknowledge a positive test result is an indication that I must self-isolate and wear a mask or face covering as directed to avoid infecting others. I understand, as with any medical test, this COVID-19 test has the potential for reflecting a false positive or false negative result. I agree to seek medical advice, care, and treatment from my healthcare provider if I have questions or concerns or if my condition worsens. I understand the testing organization is not acting as my primary healthcare provider, and this testing does not replace treatment by my primary healthcare provider. I understand the test purpose, procedures, possible benefits and risks, and I can request a copy of this consent form. I can ask questions before I sign this consent form, and I understand I can ask additional questions at any time. I understand there will be no out of pocket charge for the tests, the costs will be covered by my health insurance, CARES Act funding for the uninsured, and or other CARES Act funding. I hereby consent and give permission to Four Corners Testing to bill my insurance provider for this testing.
Consent Minor
The purpose of this “Child COVID-19 Testing Consent Form” is for parents or legal guardians to consent to COVID-19 testing for their children for the improved safety of each child, and the whole community. I authorize my child to be administered COVID-19 testing, as needed. I authorize this testing unit to conduct collection and testing for COVID-19 through a nasal swab to screen for COVID-19. For those children who are not able to receive a nasal swab test, a cheek/under tongue swab test can be conducted. I authorize this testing unit to share my child’s test results with others for the sole purposes of identifying others who may have been exposed. I understand my child’s test results will be shared with the County Public Health Department or to any other governmental entity the law requires. The release of any legally privileged and confidential records (e.g. educational and/or medical records) will be in accordance with applicable privacy protection laws, including the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA). I assume complete and full responsibility to take appropriate action with regard to my child’s test results. I acknowledge a positive test result is an indication my child must self-isolate and wear a mask or face covering as directed to avoid infecting others. I understand, as with any medical test, this COVID-19 test has the potential for false positive (test is positive but my child does not have the infection) or false negative (test is negative but my child has the infection) results. I agree to seek medical advice, care, and treatment from my healthcare provider if I have questions or concerns or if my child’s condition worsens. I understand the testing unit is not acting as a healthcare provider, and this testing does not replace treatment by a healthcare provider. I understand the test purpose, procedures, possible benefits and risks, and I can request a copy of this consent form. I can ask questions before I sign this consent form, and I understand I can ask additional questions at any time. I understand there will be no out of pocket charge for the tests, the costs will be covered by my health insurance, CARES Act funding for the uninsured, and or other CARES Act funding. I hereby consent and give permission to bill my insurance provider for this testing. It is also my understanding that the cost of the test may be covered by Medicaid or a similar public health funded insurance program.
Name
*
First Name
Middle Name
Last Name
Parent / Guardian Name
First Name
Middle Name
Last Name
Date of Birth
*
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Day
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Year
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
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Arkansas
California
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Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
How do you want to be notified?
Text
Email
Both
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Insurance Coverage
The following insurance information is provided for the express purpose of authorizing you to obtain payment for the COVID test you are providing:
What type of Insurance Do You Have?
Individual
Group
Medicare
Uninsured
Other
Name of Insurance Company
*
Policy Number
*
Group Number
Name of Primary Insured
Name of company providing group coverage
Insurance Card Front
Insurance Card Back
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of
Sex
*
Male
Female
Undefined
Ethnicity
*
Please Select
Hispanic or Latino
Non-Hispanic or Latino
Undisclosed
Race
*
Please Select
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Prefer Not To Answer / Undisclosed
Form of ID *For Identification Purposes Only
Please Select
Drivers License
Social Security Card
Student ID
Other
None
Screening Questionnaire
Are you currently experiencing any Covid-19 symptoms?
*
No
Yes
Do you have a fever, or have you felt feverish recently?
*
Yes
No
Have you lost your ability for taste or smell?
*
Yes
No
Do you have a cough?
*
Yes
No
Do you have shortness of breath or difficulty breathing?
*
Yes
No
Do you have chills or repeated shaking with chills?
*
Yes
No
Do you have any muscle pain or body aches?
*
Yes
No
Have you had a recent headache or sore throat?
*
Yes
No
Have you been experiencing nausea and/or vomiting?
*
Yes
No
Have you been experiencing fatigue lately?
*
Yes
No
Have you been experiencing an upset stomach or diarrhea?
*
Yes
No
Have you been advised to self-quarantine?
*
Yes
No
Have you traveled in the past 14 days to any places affected by Covid-19?
*
Yes
No
Have you been tested for Covid-19?
*
Yes
No
If yes, what was the result?
*
Yes
No
Have you ever been diagnosed with Covid-19?
*
Yes
No
If yes, when? MM/DD/YYYY
Are you over age 65?
*
Yes
No
Have you been vaccinated?
*
Yes
No
Do you have?
*
Heart Disease
Lung Disease
Kidney Disease
Autoimmune Disorders
Diabetes
None
Reason for Testing
Please Select
Exposed
Exhibiting Symptoms
Suspected Exposure
Primary Care Doctor Name
*
I understand that if I'd like to speak to a medical professional at any time, one will be made available to me via virtual consultation.
*
Agree
Don't Agree
Signature
*
Location
Service Type
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