Rapid COVID-19 Test Intake Form
Do you consent to being tested for COVID-19?
YES
NO
(If under 18 you must be accompanied by a parent/guardian or have written permission from a parent/
guardian to be tested. Name of primary parent/guardian associated with this test________________)
Do you currently have any symptoms a
ssociated with COVID-19, even if mild?
YES
NO
________________________________________________________________________________________
Last Name First Name
Date of Birth Contact Phone
Email
Employer and/or School Phone Number for Employer
Primary Care Provider (If you have one) Phone Number for Provider
Gender
Male
Female
Unknown
Other
RACE
American Indian/Alaska Native
Asian
Black
Native Hawaiian/Pacific Islander
White
ETHNICITY
Hispanic
Non-Hispanic
You will be notified of your results by phone within 3 hours of taking this test, as long as you answer your
contact phone listed above. Within 48 hours, you will also receive a PDF email of these results, if you provided a
valid email above. Please make sure all information on this form is either typed or written clearly.
Result: Positive Negative w/ Symptoms Negative Invalid
Patient Informed of Result by Phone? YES NO
Test Type: Binax
Dev. 12/2020
PARTICIPANT INFORMATION: Please fill this entire section
Lab Result Information: Staff Use Only
Time Read:
_____________
***this is not an official result notification form***
ID Now
NO, but left message informing of email
Date & Location:____________ Initials:_______
County of residence: Genesee Orleans Other:____________________
Exp._____ Lot#_______
_____________
Code: ____________
