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Covid Testing Form

Gathers a patient's personal, demographic, and insurance details ahead of a COVID test, along with signatures from both the provider and the patient.

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Page 1

Name

Nombre

Apellido

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Phone Number

Birthdate

Sex

Male Female Other

Have You Recently Traveled?

Yes No

Have you had any of these symptoms in the last 14 days?

Fever Cough Shortness of breath Sore throat Loss of taste or smell Fatigue

Languages Spoken

English Spanish Portuguese Other

Race

White Black/African American Asian Native American Pacific Islander Other

Ethnicity

Hispanic/Latino Not Hispanic/Latino

Page 2

NPI No.

Name

Nombre

Apellido

Signature

Sign here

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Facility Name

Phone Number

Page 3

Insurance Name

Nombre

Apellido

Policy's number or Insurance ID

Section

Insurance Group Number

Date

Patient's Signature*

Sign here

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