Home
Mission & Vision
SERVICES
X-Rays
3D 4D Ultrasound
Bone Densitometry
Sleep Disorders Center
Interventional Radiologist
Ultrasound
MRI, PET/CT & CT Scan
COVID-19 Testing
BILLING & INSURANCE
Physicians
Meet Our Team
Contact Us
Menu
Home
Mission & Vision
SERVICES
X-Rays
3D 4D Ultrasound
Bone Densitometry
Sleep Disorders Center
Interventional Radiologist
Ultrasound
MRI, PET/CT & CT Scan
COVID-19 Testing
BILLING & INSURANCE
Physicians
Meet Our Team
Contact Us
COVID-19 Testing
Home
COVID-19 Testing
COVID-19 Testing Registration & Consent Form
Full Name
*
First Name
Last Name
Date of Birth
*
Gender
*
Male
Female
Other
Phone Number
*
Phone Number
Email
*
Email
Address
*
Street Address
Street Address Line 2
City
State
Postal code
Nursing Facitity
Location
Livermore, California
Los Angeles, California
Phoenix, Arizona
Chicago, Illinois
Primary Insurance
Specific Plan Name
Policy Number
Group Number
Doctor Name
Doctor Number
Upload ID
In the past 14 days have any? (Check all that apply)
*
Fever
Chills
Cough
Shortness of Breath OR Difficulty Breathing
Fatigue
Muscle OR Body Aches
Headache
New Loss of Taste OR Smell
Sore Throat
Congestion OR Runny Nose
Nausea OR Vomiting
Diarrhea
NO SYMPTOMS
In the past 14 days, have you had close contact (< 6 feet for >15 minutes) with anyone with the following? (Check all that apply)
*
Person with COVID-19 who has symptoms (listed above) that had a positive test OR was diagnosis based on clinical symptoms
Person who has tested positive for COVID-19 but has not had any symptoms
None of above
I agree to
Terms and Conditions
.
Signature
Clear