Confidential COVID-19 Provider TESTING Form
***THIS SERVICE IS for MARIN COUNTY RESIDENTS ONLY.
***NON-RESIDENTS SHOULD BE REFERRED TO THEIR RESPECTIVE HEALTH DEPARTMENTS.
***We will be prioritizing testing for urgent care referrals and patients at high risk for COVID-19
***This form is for referring suspected cases for field-based testing through the health department. If you would like to report testing that was done outside of the health department, please us this form: https://forms.gle/bgCUym9iVrHPYwuh6
By checking this box I certify that the provider has read the criteria for COVID-19 testing (located at https://www.marinhhs.org/coronavirus-health-care-providers) and has reviewed it with my patient, including the requirement that patients will have to self-quarantine pending results of their test. *
Required
Person completing form *
Your answer
Hospital or Facility *
Your answer
Is referral from urgent care practice? *
Provider Phone Number *
Your answer
Provider Fax Number
Your answer
Provider Email *
Your answer
I prefer to receive my results through:
Next
Never submit passwords through Google Forms.
This form was created inside of Health and Human Services - Marin County. Report Abuse
Google Forms