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COVID-19 Screening
Pre-Registration Form
First Name *
Last Name *
Address *
Date of Birth *
MM
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DD
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YYYY
Email Address *
Phone Number *
Requested Testing Date *
MM
/
DD
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YYYY
Are you experiencing any FLU/COVID-19 symptoms? *
Please describe COVID-19 or Flu like Symptoms
Do you have insurance? *
Name of Insurance Provider
Member ID#
Insurance Group#
I affirm I have no health coverage, such as individual, employer sponsored, Medicaid, Medicare, federal or otherwise. Therefore, I affirm that the above patient qualifies as uninsured according to the COVID-19 program without insurance in the coronavirus aid relief and economic security (CARES) ACT (PL 11-136)I am aware that my insurance will be billed by the COVID-19 test if you are not rated uninsured under the COVID-19 uninsured program. *
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