COVID-19 Testing Registration & Consent Form
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Specific Plan Name
Do you have a history of, or currently have, any of the following health conditions? (Check all that apply)
Immune System Dysfunction
Congestive Heart Failure
Coronary Artery Disease
Heart Muscle Condition (Cardiomyopathy)
Obesity (BMI > 30)
Sickle Cell Disease
Type 1 or Type 2 Diabetes Mellitus
PAST MEDICAL HISTORY Do you have any other chronic medical conditions (in addition to those above)?
Please list any chronic medical conditions you have
Do you have any medication allergies?
Please list any drug allergies you may have
Are you currently taking any medication?
Please list any prescription or OTC medications or supplements you take regularly
Do you currently smoke or use tobacco products?
In the past 14 days have any? (Check all that apply)
Shortness of Breath OR Difficulty Breathing
Muscle OR Body Aches
New Loss of Taste OR Smell
Congestion OR Runny Nose
Nausea OR Vomiting
In the past 14 days, have you had close contact (< 6 feet for >15 minutes) with anyone with the following? (Check all that apply)
Person with COVID-19 who has symptoms (listed above) that had a positive test OR was diagnosis based on clinical symptoms
Person who has tested positive for COVID-19 but has not had any symptoms
COVID Screening Consent:
By signing below I give permission for Medford Chemists staff to perform a COVID-19 test on me. The testing process has been explained to me and I have had an opportunity to ask any questions I may have. I acknowledge that Medford Chemists cannot guarantee the accuracy of the result and that it may be necessary for me to undergo additional testing in the future. I recognize that even if I have a negative result now, I can still contract COVID-19 in the future. Administering the test does not create a patient/physician relationship between me and Medford Chemists or any of its employees, nor does it obligate Medford Chemists or its staff to perform any other care or treatment for me. I authorize Medford Chemists to receive my test results and convey them to me. I understand by undergoing the test Medford Chemisits may have to report the results to the Department of Health or other agencies. I fully release and discharge Medford Chemists Inc.., its affiliates, directors, and employees from any liability for illness, injury, loss, or damage which may result. I further agree that while this testing is being billed by Medford Chemists Inc. that I am financially responsible for any copay or co-sharing amount no covered by my insurance at the time of service.
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