Test page


    *DATE: *School / Colegio:
    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 breathMuscle or body achesSore throatNew loss of smell or tasteDiarrheaNausea or vomitingNew fatigue/malaiseRunny nose/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
    *