Senior Residence Testing Entry Consent Form
Use this form to register for a testing visit at a senior residence and confirm the information needed for safe entry and participation.
Participant Information
Full Name
*
First Name
Last Name
Preferred Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Senior Residence and Visit Details
Senior Residence Name
*
Unit, Room, or Location
*
Scheduled Testing Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Scheduled Testing Time
*
Hour Minutes
AM
PM
AM/PM Option
Test Type, Visit Purpose, or Access Notes
Access, Health Screening, and Assistance Needs
Do you need mobility assistance for this visit?
*
Yes
No
Will you require an escort during the visit?
*
Yes
No
Which assistive devices will you use?
Walker
Wheelchair
Cane
Hearing aid
Other
Do you have any access restrictions we should know about?
Yes
No
Entry safety screening: are any of the following true today?
*
Current fever
New cough
Shortness of breath
Recent exposure to a contagious illness
None of the above
Additional access notes
Emergency Contact and Consent
Emergency Contact Name
*
First Name
Last Name
Relationship to Participant
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: