DTP-44970 Mott Haven Academy Charter School ACCT#44970 170 Brown Place Bronx, NY 10454 PLEASE CHOOSE TEST FREQUENCY Days of a week: SunMonTueWedThuFriSat End day of repeat (max 1 year): PERSONAL INFORMATION * * *DOB: *GENDER: MALEFEMALE * * *STATEAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming * * * *RACEASIANAFRICAN AMERICAN / BLACKCAUCASIAN / WHITEHISPANIC / LATINONATIVE AMERICAN / ALASKAN NATIVENATIVE HAWAIIAN / OTHER PATHIFIC ISLANDERMIXEDOTHER *ETHNICITYHISPANIC OR LATINONOT HISPANIC OR LATINOOTHER INSURANCE *I HAVE INSURANCE YESNO * * 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 *By clicking this box, I voluntarily consent to the collection and testing of my specimen and the release of the testing results to the ordering provider/facility, however such results shall be used solely for clinical diagnostics/treatment purposes and shall not be used for any forensic purposes related to my employment or other legal or administrative purposes. The specimen identified by this form is my own, is fresh and unaltered. I authorize Accu Reference to bill my insurance directly for services I receive and acknowledge that Accu Reference may be an out of network provider with my insurance. I am aware that in some instances my provider may send payment directly to me, in such instances I agree to endorse the check and forward it to Accu Reference Medical Lab within 30 days.