HAZLET PHARMACY POCT Covid Antigen Testing

Point of Care Testing for COVID19
Patient Intake and Assessment Form
2874 Highway 35 Hazlet, NJ 07730
Patient Name
Gender
Birth Date
MonthDayYear
2 digit month, 2 digit day, 4 digit year1
Address
Patient Address
Street Address Line 2
City/State/ZipState / Province
Postal / Zip Code
Patient Phone Number
Format: (000) 000-0000.
Patient Weight
Primary Care Physician
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Physician Address
Medication Allergies
Current Medications
Past Medical History
Current Situation When did your symptoms start?
Date exposed to COVID 19 (if known)?
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Which of these symptoms do you currently have?
Fever?
What temperature?
Cough?
Vomiting?
Diarrhea?
Shortness of Breath?
Chills?
Sore Throat?
Muscle Pain?
New loss of Taste or Smell?
Have you taken any medications for these symptoms?
If yes, what have you taken, and when?
Do you have any of the following medical conditions?
Have you been prioritized by your local health department for testing?
Are you a health care worker, first responder, or law enforcement officer?
Do you live or work in a treatment facility, group home, or other group setting?
Are you a caregiver for an elderly person or someone with a weakened immune system?
Should be Empty:

Select theme: