DTP-43254


    *DATE:

    PERSONAL INFORMATION

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    *DOB:

    *GENDER: MALEFEMALE

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    INSURANCE

    *I HAVE INSURANCE
    YESNO

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    *Insurance Card Photo Front

    *Insurance Card Photo Back

    *Government Issued ID

    *PATIENT RELATIONSHIP TO INSURED

    SELFCHILDSPOUSEOTHER

    *Government Issued ID

    REASON FOR TESTING QUESTIONNAIRE

    I have symptomsI have household member with symptomsWorkSchoolTravelOther

    CoughFever/ChillsShortness of breath/Difficulty breathingMuscle or body acheSore throatAcute sore throatNew loss of smell or tasteDiarrheaNauseaNausea and vomitingVomiting onlyNew fatigue or malaiseRunny nose or congestion

    *Have you had close contact with someone diagnosed with COVID-19? YESNO

    *Have you been notified that you may been exposed to COVID-19? YESNO

    *Recent travel to high prevalence of COVID-19? YESNO

    Personal Medical History, Check if applies:

    Do you have AsthmaCOPDSleep apneaHigh blood pressureHeart issue

    TEST

    C455 COVID-19, PCR

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