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COVID-19 Test Registration Form

Collects personal details, allergy history, and current symptoms to register a patient ahead of their COVID-19 test.

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Page 1

Name

Nombre

Apellido

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Phone Number

Gender

Male Female Other

Height

Weight

Page 2

Do you have any allergies to any medication?

Yes No

Please Specify

Do you have any seasonal allergies

Yes No

Please Specify

Do you have any food allergies

Yes No

Please Specify

Are you taking medications for your allergies

Yes No

Please Specify

Are you currently under medication?

Yes No

Please Specify and Explain the Purpose

Page 3

Mode of Payment for the Test

Cash Credit/debit card Insurance Online payment

Current Temperature Reading

Are you experiencing shortness of breath, and coughing?

Yes No

Did you travel outside the state or country within the last 14 days?

Yes No

Have you travelled outside the state or country within the last 14 days?

Yes No

Have you had contact or exposure with someone who has been confirmed to have a case of COVID-19 infection?

Yes No

Do you have a fever?

Yes No

Do you have any other pre-existing medical condition?

Yes No

Please indicate all here

I certify that the information provided above is true and complete.

Name

Nombre

Apellido

Signature

Sign here

Date

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