COVID-19 Test Demographic Consent Form
Should be filled out prior to every COVID-19 PCR Test.
Test Location
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Gender
Please Select
Male
Female
N/A
Nationality
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason For Testing
Travel
Workplace requirement
Symptomatic
Exposure to a case
Other
Occupation
Vaccination Status
Please Select
Fully vaccinated
Not vaccinated
Do you have any of the following symptoms? (Please check all that apply.)
Fever
Cough
Tiredness
Loss of taste or smell
Sore throat
Headache
Aches and pains
Diarrhoea
Difficulty breathing, shortness of breath
Chest pain
Loss of speech or mobility, or confusion
Other
Symptoms started on
-
Month
-
Day
Year
Date
Have you traveled in the past 14 days?
Yes
No
Date & Time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Signature
Submit
Should be Empty: