HCS COVID-19 Testing

Who is being tested?

StudentStaffParent/Guardian

Testee Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Photo ID

Cancelof

Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Relationship*
Parent/Guardian Phone Number*
Parent/Guardian Email*
example@example.com

Insurance Information
Payer Name*
Member Policy #*
Group Plan #
Insured Name*
Relationship to Subscriber*
Insurance Card*

Cancelof

Lab Name
Account Number
Lab Test Name
Lab Test Code
Company Name
Practice Name

Authorization to Test
1. I attest that I, {parentguardianName}, authorize Agile Urgent Care to test my child or legal charge for COVID-19 through a saliva test or nasopharyngeal swab without my presence.
2. I understand that this testing may occur at multiple points throughout the 2020-2021 school year. I will contact the school to revoke this authorization if I wish for testing to cease.
3. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.
4. I authorize my test results to be disclosed to Hoboken Charter School.
By signing this form, I am attesting that I have the requisite legal authority and power to make the decisions for, and on behalf of, the student named above that I am making on this form.
1. I attest that I, {name}, authorize Agile Urgent Care to test me for COVID-19 through a saliva test or nasopharyngeal swab.
2. I understand that this testing may occur at multiple points throughout the 2020-2021 school year. I will contact the school to revoke this authorization if I wish for testing to cease.
3. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.
4. I authorize my test results to be disclosed to Hoboken Charter School.
1. I attest that I, {name}, authorize Agile Urgent Care to test me for COVID-19 through a saliva test or nasopharyngeal swab.
2. I understand that this testing may occur at multiple points throughout the 2020-2021 school year. I will contact the school to revoke this authorization if I wish for testing to cease.
3. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.
Signature*

Clear

Schedule your Test*
Should be Empty:

Testee Information

Parent/Guardian Information

Insurance Information

Authorization to Test