Pre-Registrations

Last NameFirst NameEvent DateEvent LocationEmailPhoneAddressWhat county do you live in?Driver's License FRONT PhotoDriver's License BACK PhotoDate of BirthGenderAre you pregnant?EthnicityInsurance Info (optional)Who is your insurance provider?What's your group number?What's your policy number?Insurance 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 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) TESTINGAGREEMENT FOR SELF-ISOLATIONPATIENT CONSENT
Last NameFirst NameEvent DateEvent LocationEmailPhoneAddressWhat county do you live in?Driver's License FRONT PhotoDriver's License BACK PhotoDate of BirthGenderAre you pregnant?EthnicityInsurance Info (optional)Who is your insurance provider?What's your group number?What's your policy number?Insurance 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 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) TESTINGAGREEMENT FOR SELF-ISOLATIONPATIENT CONSENT