Pre-Registrations

Last Name	First Name	Event Date	Event Location	Email	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
Last Name	First Name	Event Date	Event Location	Email	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