Covid -19 Rapid Test
Full Name
*
Patient Date of Birth
*
Address
*
City
*
State
*
Postal code
*
Phone
*
Email
*
Sex
Male
Female
Ethnicity
*
Is this your first Covid-19 test?
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Yes
No
Pregnant
Yes
No
Health Conditions:
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
Text
Do you work in a healthcare setting?
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Yes
No
If yes, role:
Do you work in a long term care facility?
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Yes
No
If yes, setting:
Car make / model / color
*
Method of Payment
*
Method of Payment
If you choose Credit Card - Fill out Credit Card Info
Card Expiration
CVC
Below line will be filled out by administrator:
------------------------------------------------
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 ____________
Submit