COVID-19 RT-PCR Request Form

COVID-19 RT-PCR Request Form
Please submit this form to request a Real-Time PCR Testing, and make sure that the information you provide is accurate and complete.
Date
MonthDayYear
Date
Patient Information
Patient Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Age
Gender
MaleFemale
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Reason for the Test
Previously diagnosed with COVID-19 by RT-PCRDiagnosed as COVID-19 Positive by a Rapid TestClearance for WorkClearance for SurgeryHealthworkerHigh Risk Group (Pregnant/Elderly/Underlying Medical Conditions)Scheduled FlightExposed to a COVID-19 Positive PatientExhibit Symptoms of COVID-19Other
Appointment
Select a time slot
Consent
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
Clear
Should be Empty:

Patient Information