Established Patient

  • 1Enter Confirmation Number
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  • 2Patient Information
    Have you had any of these symptoms in the past 24 hours?*
    Do you have any high-risk medical conditions?*
    Have you come into contact with any person who has tested positive for COVID-19?*
    Have you recently traveled?*
    Are you a healthcare worker with direct contact with patients?*
    Are you in close contact with anyone over age 65, with an impaired immune system, with diabetes, liver disease, lung disease, or who is pregnant?*

    INFORMED CONSENT FOR COVID-19 TESTING

    I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a blood test and, if the result is positive, to be followed with a nasopharyngeal swab as needed for confirmatory.

    AGREEMENT FOR SELF-ISOLATION

    The local health jurisdiction has determined that if you are under suspicion for having COVID-19 due to symptoms and testing requests, it is necessary to be placed in isolation in order to prevent the transmission of this infection. It is important for you to comply with this Isolation Agreement in order to protect the public’s health.

    Your signature below confirms that you consent to COVID-19 testing, and, if you have any of the symptoms above, you will isolate yourself from any other people until you receive a negative test result.

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