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COVID-19 Test Request Form

Lets a health facility receive COVID-19 test requests, including symptoms, exposure history, and prior test results.

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Name

Nombre

Apellido

Age

Gender

Male Female Other

Date of Birth

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Race/Ethnicity

Job Position/Title

Company Name

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?

What are the symptoms you're currently experiencing?

Fever Cough Shortness of breath Sore throat Loss of taste or smell None

Do you have any of the medical condition below:

Diabetes Heart disease Asthma Chronic kidney disease Cancer None

Collection Date

Specimen Type

Nasopharyngeal swab Oropharyngeal swab Saliva Blood

Specimen Source

Nose Throat Saliva Blood

Have you been tested for influenza?

Yes No

If yes, what is the influenza test result?

Positive Negative Pending

What type of influenza test?

Rapid antigen PCR Other

Have you been tested for COVID-19

Yes No

If yes, what is the COVID-19 test result?

Positive Negative Pending

What type of COVID-19 test?

PCR Rapid antigen Antibody

Additional Notes

Patient Signature

Sign here

Date Signed

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