COVID-19 Test Registration Form

COVID-19 Test Registration Form
Name
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Gender
MaleFemale
Height
Weight
lbs

Do you have any allergies to any medication?
YesNo
Please Specify
Do you have any seasonal allergies
YesNo
Please Specify
Do you have any food allergies
YesNo
Please Specify
Are you taking medications for your allergies
YesNo
Please Specify
Are you currently under medication?
YesNo
Please Specify and Explain the Purpose

Mode of Payment for the Test
Health card/MedicareInsuranceHSA/FSASelf pay
Current Temperature Reading
Are you experiencing shortness of breath, and coughing?
YesNo
Did you travel outside the state or country within the last 14 days?
YesNo
Have you travelled outside the state or country within the last 14 days?
YesNo
Have you had contact or exposure with someone who has been confirmed to have a case of COVID-19 infection?
YesNo
Do you have a fever?
YesNo
Do you have any other pre-existing medical condition??
YesNo
Please indicate all here
By signing below, I hereby acknowledge that I will undergo testing for COVID-19 and I hereby understand the risks and benefits of such. I willfully give my consent in making use of my information for statistical purposes only as well as relative information for which I may be notified.
Name
First NameLast Name
Signature
Clear
Date
MonthDayYear
Date
Should be Empty: