EASY TESTING RESERVATION

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Last Name *

First Name *

Testing date *

YYYY

Date of birth *

YYYY

Cell phone number (you may be receiving a text notification from the lab with notifications regarding your results) *

(###) ###-####

Sex *

Street (Address) *

Street (Line 2)

City *

State *

Zip Code *

Are you Hispanic or Latino? *

Yes

Race? *

White American, European American, or Middle Eastern American

Black or African American

Native American or Alaska Native

Asian American

Native Hawaiian or Other Pacific Islander

Other:

Required

Are you experiencing any of the following symptoms? (Please select all that apply). *

Fever (98.6°F-102°F)

High Fever (>102°F)

New or worsening cough

Shortness of breath

Chills

Sweating

Sore Throat

Body Aches

Vomiting or Diarrhea

other

none

Required

Please select any chronic conditions that apply below: *

Asthma or other chronic lung disease

Pregnancy

Weakened immune system

High blood pressure

Hypertension

Type I Diabetes

Type II Diabetes

Cardiovascular disease

Cirrhosis or other chronic liver disease

Extreme obesity

I currently undergo chemotherapy or radiation for cancer

Kidney failure or need dialysis

Autoimmune Disease requiring medication

ICU patient

Catheter

Patients on ventilators

I’ve had surgery in last 30 days

I have a wound or fungal infection

I currently experience immune system suppression (for example, HIV positive, have had an organ transplant, or are taking medications that suppress the immune system)

other

none

Required

How many people live in your household? *

In the last 14 days, have you been, to your knowledge, in an area where COVID-19 is widespread? *

In the last 14 days, what is your exposure to others who are known to have COVID-19? *

By checking the box, you certify that you have read and agree to Easy Testing's Policies (https://www.easytesting.com/policies), and are voluntarily scheduling an appointment to provide a fresh and unadulterated specimen for analytical testing and you authorize the Lab(s) or their assignees to process and administer results pursuant to HIPAA, PHI, and CCPA regulations. *

I agree

Required

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information, and your rights, under the law. You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. By Signing (type first and last name) below, you consent to our use or disclosure of your protected healthcare information. *

May we communicate with you via phone call? *

Yes

Required

May we communicate with you via e-mail? *

Yes

Required

May we leave a message/voicemail when we make a phone call to you? *

Yes

Required

May we discuss your medical condition with anyone other than you, the patient? *

Yes

Required

If yes, please list first name, last name and cell phone number of all authorized contacts below:

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