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.
Patient name *
Date of birth *
MM
/
DD
/
YYYY
Date of your appointment *
MM
/
DD
/
YYYY
Does the patient have any symptoms? *
If yes, please check the symptoms
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. *
Required
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. *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy