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COVID-19 CONSENT TO TEST FORM
Pratt USD 382 COVID-19 Pilot Program Consent to Testing
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* Indicates required question
Last Name
*
Your answer
First Name
*
Your answer
Cell Phone Number (this number may be used to text a reminder to you of your scheduled appointment and time)
*
Your answer
Email address (this address may be used to remind you of your scheduled appointment)
Your answer
Please indicate the date symptoms began. (If testing for a reason other than symptoms please enter the date you are filling out the form)
*
MM
/
DD
/
YYYY
Please indicate the last date of contact with the COVID positive person. (If filling out this form for a reason other than exposure, pleas enter the date you are filling out the form)
*
MM
/
DD
/
YYYY
I have at least one school aged (PREK - 12) child I would like tested.
*
Yes
No
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