ECSU COVID-19 Spread Mitigation Program
Appointment Request Form
First name *
Middle name
Last name *
Birthdate *
MM
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DD
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YYYY
Gender *
Ethnicity *
Please select the county (site) you want to get tested at. *
Street address
City
State
Zipcode
E-mail address *
Home phone (Do not use dashes)
Cell phone (Do not use dashes) *
Preferred contact for scheduling appointment *
Required
Acknowledgment *
Required
DISCLAIMER
1. That I am making this request voluntarily on my own
2. That I understand that the result of the test will neither be guaranteed nor certified
3. That any action that I take after receiving a test result is completely my decision
4. That I am releasing ECSU, its employees including those directly responsible for this service from all liabilities, obligations, or consequences that might be attributed fully or partly from this service
5. That I understand in accordance with healthcare regulations, my result may be reported to the local health department if I am positive.
6. That I understand that if my sample result in a positive, it will send for further analysis to identify the virus strand.
Signature *
Please print clearly.
Today's date *
MM
/
DD
/
YYYY
Submit
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