COVID-19 Patient Test Request Form and AgreementCovid-19 Patient Test Request Form and Agreement • December 17th, 2022
Patient Information: Completed by Patient or Guardian Specimen Collection Date: Clinician Name (if applicable): First Name: Last Name: Address: City: State: Zip Code: County: Email (Print Clearly): Phone Number: Date of Birth: Age: Sex: □ Non-Binary □ Male □ Female Does the patient live or work in a congregate setting (e.g., long-term care facility, shelter, group home, prison) □ YES □ NO Patient ClinicalInformation Date of symptom onset: Symptoms Observed: □ None Does the patient have any underlying conditions? □ Fever □ None □ Immunocompromised □ Tiredness □ Runny nose □ Unknown □ Pregnant □ Dry Cough □ Loss of smell □ Diabetes □ Chronic Lung Disease □ Body Ache □ Diarrhea □ Hypertension □ Chronic Liver Disease □ Nasal Congestion □ Loss of Appetite □ Cardiac Disease □ Chronic Kidney Disease LABORATORY TESTING –Completed by Patient □ Other Has the patient received the COVID-19 Vaccine? □ Yes □ No Which COVID-19 Vaccine has the patient received? □ Modern
