Pre-Registrations
Last Name | First Name | Event Date | Event Location | Phone | Address | What county do you live in? | Driver's License FRONT Photo | Driver's License BACK Photo | Date of Birth | Gender | Are you pregnant? | Ethnicity | Insurance Info (optional) | Who is your insurance provider? | What's your group number? | What's your policy number? | 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 | |
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Last Name | First Name | Event Date | Event Location | Phone | Address | What county do you live in? | Driver's License FRONT Photo | Driver's License BACK Photo | Date of Birth | Gender | Are you pregnant? | Ethnicity | Insurance Info (optional) | Who is your insurance provider? | What's your group number? | What's your policy number? | 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 |