ADMINISTRATIVE OFFICES
224 - D Cornwall Street Suite 403 Leesburg, VA 20176 Ph: 703.737.6010
COVID COMMUNITY TESTING REGISTRATION FORM
PLEASE PRINT CLEARLY
First Name: ______________________________ Last Name: _____________________________________
Date of Birth: _______________________________ Gender: [ ] Male [ ] Female
Street Address: _____________________________________________________________________________
City: ____________________________________ State: __________ Zip Code: _____________________
Cell Number: ______________________________ Home Number: _____________________________
1. Race: [ ] Asian [ ] Asian Indian [ ] Black/African American [ ] American Indian/Alaska Native
[ ] Other [ ] White
2. Ethnicity: [ ] Hispanic/Latino [ ] Not Hispanic/Latino
3. Have you been tested for COVID-19 before? [ ] YES [ ] NO
4. Are you currently symptomatic? [ ] YES [ ] NO If yes, Date Symptoms Started: _______________
(Symptoms include: fever or 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, or
diarrhea)
Females Only: Are you currently pregnant? [ ] YES [ ] NO
LMG – SML - TESTING FOR COVID-19
Today you are being tested for COVID-19 via a diagnostic test. By completing this form, you are stating that you consent
to testing and agree to this waiver.
Di
agnostic Test
A diagnostic test tells you if you have an active infection. This test is manufactured by Roche Laboratories and run on
Roche Instrumentation. The RT-PCR specimen requirement is a nasopharyngeal swab. It looks for the genetic material of
the coronavirus. The test uses a technology called PCR (polymerase chain reaction), which greatly amplifies the viral
genetic material if it is present.
Re
ceiving Test Results
• Positive for COVID-19: All Positive COVID-19 results will be communicated to the individual by an LMG
Provider with further instructions.
• Negative: All Negative COVID-19 results will be communicated by text message to individual.
By
completing this form, I agree that:
• I understand there are no guarantees about testing.
• There can be false positives and negatives.
• I understand that follow-up measures (such as self-isolation), symptom management, and possibility of being
contagious will not be based on this test alone. These will be based on symptoms and possible exposure.
