PCR COVID TEST INTAKE

PCR COVID TEST INTAKE

PRIVACY STATEMENT: The information collected on this form is for the use of COVID SARS-19 Testing and obtained by the City of Hartford HHS Department. Information obtained in this form can/will only be shared under the provision of the signed consent. HHS will adhere to all confidentiality guidance. * Indicates required question
Personal Information
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Email
example@example.com
Race/Ethnicity*

African American/BlackHispanic/LatinoWhiteNative Hawaiian or Pacific IslanderIndigenous/American Indian/Alaskan NativeOther
Please upload a copy of your insurance card front and back

Cancelof
Do you have a primary medical doctor (PCP) that you have seen in the last 2 years?*

YesNoYes, but I have not seen the provider in 3 or more years
In the last 7 days have you experienced any of these symptoms? Please check the symptoms that apply*

CoughFeverMuscle/Body AchesNasal congestion or Runny NoseHeadacheSore throatDiarrheaVomitingFatigue(Tiredness)ChillsShortness of BreathNone of the Above
In the last 7 days have you traveled outside of the US?

YesNo
Are you seeking this test for personal or professional reasons?*

Personal (travel, exposure, confirmatory test etc..)Professional (employment, educational, required by someone else)
Are you pregnant?

YesNoUnsure
Have you had a COVID-19 Vaccination*

YesNo
When did you receive your last COVID-19 vaccination?

MonthDayYear
Date
Do you plan to wait for your results (up to 30 min*) or prefer a phone call? If phone call is it ok to leave a message?*

I plan to wait on site for my resultsI prefer a call and it is ok to leave a message if I do not answerI prefer a call. DO NOT LEAVE A MESSAGE
Please, give your location*

Parking Spot #1Parking Spot #2Walk-in
Should be Empty:

PCR COVID TEST INTAKE

Personal Information