BHH-Back to School COVID Testing: Patient Information
This form must be completed for each individual being tested. Personal and Insurance Information is needed.

In-town parents must fill out one for themselves and another one for their child(ren).

Out of town parents must only fill out the form for their child(ren).

If your child is attending virtually, there is no need to fill out this form.

email office@hillelhigh.com for questions or comments.

thank you
Email address *
Patient Type
First Name *
Middle Initial
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Street Address *
City *
State *
Zip *
Contact Phone # *
Next
Never submit passwords through Google Forms.
This form was created inside of Shalem Healing, Inc.. Report Abuse