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
Should be Empty: