PCTC Pre-Registrations

CompletedStaff NotesFirst NameLast NameMinor ConsentDate CreatedPatientCodeOrganization CodeAre You Under 18?EmailHome PhoneMobile PhoneWork PhoneExtensionStreet AddressAddress Line 2CityStateZipWhat county do you live in?Date of BirthGenderMarital StatusAre you pregnant?RaceEthnicityPreferred Language for Future CommunicationID DocumentsDriver's License NumberDriver's License FRONT PhotoDriver's License BACK PhotoAre You Insured?Employer SponsorInsurance InfoWho is Your Insurance Provider?What's your group number?What's your policy number?Insurance DocumentsInsurance FRONT PhotoInsurance BACK PhotoWill this be your first test for COVID-19?Are you or anyone in your household employed in the healthcare industry?Are you or anyone in your household symptomatic as defined by the CDC?When were symptoms first onset?Have you or anyone in your household been hospitalized within the past 30 days?Have you or anyone in your household been admitted into the ICU within the past 30 days?Are you ill now?INFORMED CONSENT FOR CORONAVIRUS (COVID-19) TESTINGAGREEMENT FOR SELF-ISOLATIONPATIENT CONSENT
CompletedStaff NotesFirst NameLast NameMinor ConsentDate CreatedPatientCodeOrganization CodeAre You Under 18?EmailHome PhoneMobile PhoneWork PhoneExtensionStreet AddressAddress Line 2CityStateZipWhat county do you live in?Date of BirthGenderMarital StatusAre you pregnant?RaceEthnicityPreferred Language for Future CommunicationID DocumentsDriver's License NumberDriver's License FRONT PhotoDriver's License BACK PhotoAre You Insured?Employer SponsorInsurance InfoWho is Your Insurance Provider?What's your group number?What's your policy number?Insurance DocumentsInsurance FRONT PhotoInsurance BACK PhotoWill this be your first test for COVID-19?Are you or anyone in your household employed in the healthcare industry?Are you or anyone in your household symptomatic as defined by the CDC?When were symptoms first onset?Have you or anyone in your household been hospitalized within the past 30 days?Have you or anyone in your household been admitted into the ICU within the past 30 days?Are you ill now?INFORMED CONSENT FOR CORONAVIRUS (COVID-19) TESTINGAGREEMENT FOR SELF-ISOLATIONPATIENT CONSENT