Should you have questions, please contact your health care provider.
COVID-19 RAPID TEST SITE
RESULT DATA FORM
PATIENT INFORMATION
Last Name First Name MI Date of Birth Age
RACE:
☐American Indian/Alaska Native ☐Asian ☐Black ☐Native Hawaiian/Pacific Islander ☐White
ETHNICITY: GENDER:
☐ Hispanic ☐ Non-Hispanic ☐ Male ☐ Female ☐ Other
Home Address Apt# City State Zip Code
County Home Phone Cell Phone
Employer
Work Address City State Zip Code
Work Phone Occupation/Job Title
_____________________________________________________________________________________
Email
Patient attends, works or volunteers in a school? YES NO
If yes: ______________________________________________________________________________
School Name Address City State Zip Code Phone
LAB RESULT INFORMATION
Date Specimen Collected: ______________________ Specimen Source: _____________
Performing Facility Name: _____________________ Test Type: ______________
Test Result Date: ____________________________
Result (circle): Positive Negative Invalid
Patient Informed of Result (circle): YES NO
Ordering Provider Name: _____________________
Comments: __________________________________
