COVID-19 Test Request Form
Patient Data
Name
First Name
Last Name
Age
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race/Ethnicity
Job Position/Title
Company Name
Health Related Data
Is the patient currently in a hospital or long-term care facility?
Yes
No
Is the patient undergoing dialysis?
Yes
No
Date when symptoms first appeared?
-
Month
-
Day
Year
Date
What are the symptoms you're currently experiencing?
Fever
Lethargic (Tiredness)
Restlessness
Dry cough
Body ache
Nasal Congestion
Runny Nose
Loss of Smell
Diarrhea
Loss of Apetite
Do you have any of the medical condition below:
Diabetes
Hypertension
Cardiac Problems
Immunocompromised
Pregnant
Chronic Respiratory Disease
Liver Problems
Kindney Problems
Other
Collection Date
-
Month
-
Day
Year
Date
Specimen Type
Acute
Convalescent
Specimen Source
Nasal
Oropharyngeal
Nasopharyngeal
Have you been tested for influenza?
Yes
No
If yes, what is the influenza test result?
Positive
Negative
What type of influenza test?
Rapid
PCR
Have you been tested for COVID-19
Yes
No
If yes, what is the COVID-19 test result?
Positive
Negative
What type of COVID-19test?
Rapid
PCR
Acknowledgment and Consent
I acknowledge that all information I entered in this form is accurate and true.
I authorize this facility to collect a sample specimen for me in order to perform this test.
I release the facility and all of its employees and affiliates, from any liabilities, damage, or accidents related to this testing activity.
I authorize this facility to share with the requester (e.g company) my health care information including diagnostic test results and medical test results.
I understand that this diagnostic test is for informational purposes only. This facility will not admit patients or provide medical advice.
Patient Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: