New Patient COVID-19 Test Registration Form

New Patient COVID-19 Test Registration Form
- Name
  First NameLast Name
- Age
- Date of Birth
  MonthDayYear
  Date
- 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
- Occupation
- Company Name
- Emergency Contact Person
  First NameLast Name
- Emergency Contact Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Do you have an insurance coverage?
- Insurance Company Name
- Select your preferred appointment
- Reason for testing
  Other
- Weight (kg)
- Height (cm)
- Temperature F
  Farenheit
- Blood Pressure
  mmHg
- Heart/Pulse Rate
  bpm
- Do you have any allergies?
- If yes, please provide the list of allergies of the cause or trigger
- Are you currently taking any medications?
- If yes, please indicate the name of the medication and the reason or purpose
- Are you experiencing the following symptoms?
  Rows Present Not Present Remarks/Notes
  Difficulty of breathing 1 2
  Coughing 3 4
  Conjunctivitis 5 6
  Fever 7 8
  Loss of taste 9 10
  Loss of smell 11 12
  Diarrhea 13 14
  Headache 15 16
  Body weakness 17 18
- Method of Payment
- The selected date in the appointment section is subject to change. It is because that our health provider needs to talk to you first and assess you over the phone or video call in terms of eligibility and verification.
  Please make sure that you are available during the phone or video call assessment and on the appointment date to prevent any issues.
  Test results will be available for online viewing using the credentials that will be provided to you. You will also receive an email and SMS on how to open the result.
  I authorize this clinic or center to conduct COVID-19 testing for me.
- Patient Signature
  Clear
- Date Signed
  MonthDayYear
  Date
- Should be Empty:

Rows	Present	Not Present	Remarks/Notes
Difficulty of breathing	1	2
Coughing	3	4
Conjunctivitis	5	6
Fever	7	8
Loss of taste	9	10
Loss of smell	11	12
Diarrhea	13	14
Headache	15	16
Body weakness	17	18