COVID-19 Testing Registration Form
First and Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Address Line 1 *
Address Line 2
City *
State
Zip *
Phone number *
Primary Care Provider
Provider Phone Number (If known)
Employer
Birth Gender *
Preferred Language
Are you a veteran?
Clear selection
Insurance Information
Insurance
Insurance ID#
Insurance Group #
Insurance Holder
Holder's DOB
MM
/
DD
/
YYYY
If uninsured, list ID # for one of the ID types below (pick one)
Clear selection
ID#
Family/Support Information
Emergency Contact
Relationship
Phone Number
Race/ Ethnicity
Check the box that best describes your race and Ethnicity
Race *
Ethnicity *
Housing Status
Check any box that describes your current housing situation
Do you live in a group setting like an Adult Foster Care or senior community?
Clear selection
Consent *
Required
• Receiving testing and/or services by Cherry Health
• Cherry Health ordering labs/testing
• Billing insurance for care provided
• Communicating results of testing with your employer for all employer required tests
• Communicating test results to shelter / housing coordinators if accessing group living
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy