SPSV Pre-Registrations
Completed | Staff Notes | First Name | Last Name | Date Created | Custom Content | PatientCode | What is your relationship with this school? | 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 | Preferred Language for Future Communication | ID Documents | Driver's License / ID Number | Driver's License FRONT Photo | Driver's License BACK Photo | Will you be paying by cash? | Other Payment | Social Security Number | Insurance Info | 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? | 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 | Signature IP Address | Signature Page Title | Signature URL | |
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Completed | Staff Notes | First Name | Last Name | Date Created | Custom Content | PatientCode | What is your relationship with this school? | 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 | Preferred Language for Future Communication | ID Documents | Driver's License / ID Number | Driver's License FRONT Photo | Driver's License BACK Photo | Will you be paying by cash? | Other Payment | Social Security Number | Insurance Info | 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? | 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 | Signature IP Address | Signature Page Title | Signature URL |