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COVID-19 Testing Registration and Consent Form

Testing centers use this form to capture each patient's personal details, medical history, and signed consent before administering a COVID-19 test.

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Full Name*

Nombre

Apellido

Date of Birth*

Gender*

Male Female Other Prefer not to say

Phone Number*

Email*

Address*

Dirección

Ciudad

Estado / Provincia

Código postal

Primary Insurance

Policy Number

Group Number

Do you have a history of, or currently have, any of the following health conditions? (Check all that apply)

Diabetes Heart disease Asthma Cancer Kidney disease None

PAST MEDICAL HISTORY Do you have any other chronic medical conditions (in addition to those above)?*

Yes No

Please list any chronic medical conditions you have

Do you have any medication allergies?*

Yes No

Please list any drug allergies you may have

Are you currently taking any medication?*

Yes No

Please list any prescription or OTC medications or supplements you take regularly

Do you currently smoke or use tobacco products?*

Yes No

In the past 14 days have any? (Check all that apply)*

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

In the past 14 days, have you had close contact (< 6 feet for >15 minutes) with anyone with the following? (Check all that apply)

Confirmed COVID-19 diagnosis COVID-19 symptoms Recent travel abroad None of the above

Signature*

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