PHX Pre-Registrations

Completed	Staff Notes	First Name	Last Name	Event Location	Event Date	Service	PatientCode	Date Created	Event	Email	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
Completed	Staff Notes	First Name	Last Name	Event Location	Event Date	Service	PatientCode	Date Created	Event	Email	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