• COVID-19 Testing Questionnaire - Adult

  • Date of Birth*
     . .
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • If your family comes to Tosa Pediatrics for routine care, do you have the same insurance as your child?*
  • Do we have permission to text your results?*

  • Please answer the following questions. If the questions are unclear, please ask your healthcare provider.

     

  • 1a. Have you been exposed to anyone who tested positive for Covid-19 OR is waiting for test results?*
  • 2a. Do you or did you have any of the following symptoms?
  • 2b. If yes, when did they first start?
     . .
    2 digit month, 2 digit day, 4 digit year
  • 3. Are you pregnant?*
  • 4. Are you fully vaccinated for COVID-19?*
  • 5a. Have you tested positive for COVID-19 in the last 90 days?*
  • 5b. If yes, what is the date of the positive test?
     . .
    2 digit month, 2 digit day, 4 digit year
  • 6. Ethnicity*
  • 7. Race*

  • I understand that if my insurance is different from that of my child, I must provide my personal insurance. I understand that if my insurance does not cover the cost of the COVID-19 test, that I am responsible for any balance. If I am a WSD staff member, I understand that it is my responsibility to forward any balance to the WSD Human Resources Department otherwise I will be held responsible for the charges. I understand that COVID-19 is a reportable disease such that testing information including name and results will be forwarded to my local health department and possibly my school/district nurse. I authorize the staff at Tosa Pediatrics to leave a voicemail or text at the number above with any test results.

  • Date*
     . .
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: