PHX Pre-Registrations
Completed | Staff Notes | First Name | Last Name | Event Location | Event Date | Service | PatientCode | Date Created | Event | Home Phone | Mobile Phone | Work Phone | Extension | Street Address | Address Line 2 | City | State | Zip | What county do you live in? | Date of Birth | Gender | Marital Status | Are you pregnant? | Race | Ethnicity | ID Documents | Driver's License / ID Number | Driver's License FRONT Photo | Driver's License BACK Photo | Will you be using insurance? | Social Security Number | Insurance Info | Insurance Code | Who is your insurance provider? | What's your group number? | What's your policy number? | Insurance Documents | Insurance FRONT Photo | Insurance BACK Photo | Will 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 a resident in a congregate care setting? | Do you have any known respiratory illnesses? If so, what? | Are you ill now? | INFORMED CONSENT FOR CORONAVIRUS (COVID-19) TESTING | AGREEMENT FOR SELF-ISOLATION | PATIENT CONSENT | User IP | |
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Completed | Staff Notes | First Name | Last Name | Event Location | Event Date | Service | PatientCode | Date Created | Event | Home Phone | Mobile Phone | Work Phone | Extension | Street Address | Address Line 2 | City | State | Zip | What county do you live in? | Date of Birth | Gender | Marital Status | Are you pregnant? | Race | Ethnicity | ID Documents | Driver's License / ID Number | Driver's License FRONT Photo | Driver's License BACK Photo | Will you be using insurance? | Social Security Number | Insurance Info | Insurance Code | Who is your insurance provider? | What's your group number? | What's your policy number? | Insurance Documents | Insurance FRONT Photo | Insurance BACK Photo | Will 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 a resident in a congregate care setting? | Do you have any known respiratory illnesses? If so, what? | Are you ill now? | INFORMED CONSENT FOR CORONAVIRUS (COVID-19) TESTING | AGREEMENT FOR SELF-ISOLATION | PATIENT CONSENT | User IP |