COVID-19 Testing Consent Form

This form lets clinics and health centers capture a patient's contact details and record their signed authorization before administering a COVID-19 test.

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Today's Date

Name

Nombre

Apellido

Date of Birth

Phone Number

How would you like us to notify you of a negative test? A positive test will always receive a phone call.

Phone call Email Text message

Email

Reason for Testing

Possible exposure I have symptoms Recent travel Work requirement Other

You selected "Other" for why you want a test. Please explain.

Patient Consent Statement

Signature

Sign here

COVID-19 Testing Consent Form

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