Covid -19 Rapid Test
Full Name
*
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Patient Date of Birth
*
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Address
*
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City
*
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State
*
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Postal code
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Phone
*
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Email
*
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Sex
Male
Female
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Ethnicity
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Is this your first Covid-19 test?
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Yes
No
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Pregnant
Yes
No
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Health Conditions:
Diabetes
Obesity
Asthma
Immune System deficiencies/HIV
Serious heart conditions
Kidney disease needing dialysis
Liver disease
Cancer or corticosteroid use
Bone marrow/ organ transplant
Hemoglobin disorders
Other _______________________
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List is empty.
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Date symptoms began:
*
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Symptoms:
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Chills
Short of breath
Nasal drip
Vomiting
Sore throat
Nausea
Nasal congestion
Cough
Muscle pain
Loss of taste
Loss of small
Headache
Fever of > 100.4 F
Feeling feverish
Fatigue
Difficulty breathing
Diarrhea
Other
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Text
Do you work in a healthcare setting?
*
Yes
No
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If yes, role:
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Do you work in a long term care facility?
*
Yes
No
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If yes, setting:
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Car make / model / color
*
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Method of Payment
*
Method of Payment
Credit Card
Cash
Check
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If you choose Credit Card - Fill out Credit Card Info
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Card Expiration
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CVC
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Below line will be filled out by administrator:
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Date administered: _________
Time Given: __________
Time Read: __________
Lot #: __________
Expiration: __________
Test Type: BD Veritor / Carestart
Positive - Self isolate until (date) ________________ (10 days after onset of symptoms)
Negative
Administered by:______________________ Signature: ______________________________ Title ____________
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