Med History for Rapid Antigen Test

MEDICAL HISTORY for Rapid Covid Testing

This medical history is being taken prior to being tested for Covid 19 by a finger blood prick test and/or collection by nasal swab given by TOBP LLC of 2685 S Rainbow #107 Las Vegas, NV 89146.

Patient Name

Date

1) Do you have any history in the last 6 months of a major illness?

2) Do you have history of blood disorders?

3) Are you under the care of a Medical Doctor?

4) Do you take any medications?

5) Do you take any blood thinners?

6) Do you have any issue of blood clotting?

7) Do you have any allergies?

8) Do you have any history of having HIV (Aids) and/or Hepatitis?

9) Do you have an autoimmune disease? NO

By signing below, I acknowledge and agree that I have read, understand, and agreed to the answers contained within this form. I acknowledge that I have a basic command of the English language. I have been informed about the purpose of the COVID-19 diagnostic test(s), procedures to be performed, potential risks and benefits, and associated costs. I have been provided an opportunity to ask questions before proceeding with a COVID-19 test and I understand that if I do not wish to continue with the collection, testing, or analysis of a COVID-19 diagnostic test, I may decline to receive continued services. I have read the contents of this form in its entirety and voluntarily consent to undergo testing for COVID-19.

Your Signature

Date