COVID-19 RT-PCR Request Form

Date

Patient Name

First NameLast Name

Date of Birth

Date

Age

Gender

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reason for the Test

Select a time slot

I, the above-mentioned patient or his/her parent, have been informed about the COVID-19 RT-PCR Test in detail. By signing this COVID-19 RT-PCR Request Form, I hereby agree and confirm that the information provided in this request form is true and complete. I authorize the Healthcare center to forward the related information to governmental agencies.

I also agree that my clinical data and test results can be investigated and used by healthcare facilities and professionals for further scientific research. I agree to self-isolate until my test is completed.

If I test positive, I adhere to the current government guidelines relating to the COVID-19.

Patient/Parent Signature

COVID-19 RT-PCR Request Form

Patient Information

Appointment

Consent