COVID-19 Testing Registration & Consent Form
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
1
Gender
*
Male
Female
Other
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Insurance
Specific Plan Name
Policy Number
Group Number
Do you have a history of, or currently have, any of the following health conditions? (Check all that apply)
Cancer
Kidney Disease
COPD
Immune System Dysfunction
Congestive Heart Failure
Coronary Artery Disease
Heart Muscle Condition (Cardiomyopathy)
Obesity (BMI > 30)
Sickle Cell Disease
Type 1 or Type 2 Diabetes Mellitus
PAST MEDICAL HISTORY Do you have any other chronic medical conditions (in addition to those above)?
*
Yes
No
Please list any chronic medical conditions you have
Do you have any medication allergies?
*
Yes
No
Please list any drug allergies you may have
Are you currently taking any medication?
*
Yes
No
Please list any prescription or OTC medications or supplements you take regularly
Do you currently smoke or use tobacco products?
*
Yes
No
In the past 14 days have any? (Check all that apply)
*
Fever
Chills
Cough
Shortness of Breath OR Difficulty Breathing
Fatigue
Muscle OR Body Aches
Headache
New Loss of Taste OR Smell
Sore Throat
Congestion OR Runny Nose
Nausea OR Vomiting
Diarrhea
NO SYMPTOMS
In the past 14 days, have you had close contact (< 6 feet for >15 minutes) with anyone with the following? (Check all that apply)
Person with COVID-19 who has symptoms (listed above) that had a positive test OR was diagnosis based on clinical symptoms
Person who has tested positive for COVID-19 but has not had any symptoms
Signature
*
Submit
Submit
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