Tenth Street COVID Drive Through Screening Questions
Please complete this form prior to coming for drive through testing. There must be one form completed per person (do not group a family). Completing this form does not create an appointment. You MUST call the office to schedule an appointment at our drive though prior to completing this questionnaire.
Date of birth
Date of your appointment
Does the patient have any symptoms?
If yes, please check the symptoms
Shortness of breathe
Has the patient been exposed to someone with a known COVID infection?
I agree to pay a non-refundable $40 curbside convenience fee. This fee will not be submitted to insurance.
I understand that this test has been cleared for diagnostic use by the US FDA under Emergency Use Authorization (EUA) usage only. A negative test results does not preclude COVID-19 as low levels of SARS-CoV-2 may be undetectable and result should be combined with clinical observations.
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