COVID-19 Testing Registration
Test Location
*
27th Avenue Health Center - 3864 N 27th Ave, Phoenix, AZ 85017
McDowell Health Center - 4919 E McDowell Road #7735, Phoenix, AZ 85008
Olive Health Center - 6153 W Olive Ave, Glendale AZ 85302
Stapley Health Center - 1111 S Stapley Dr., Mesa, AZ 85204
PATIENT INFORMATION
Patient's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Driver's License #:
Birth Gender
*
Male
Female
Preferred Language
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I am a:
*
Terros Health Patient
Terros Health Employee
First Responder
Healthcare Worker
Other
Race
American Indian/Alaskan Native
Asian
Black/African-American
Native Hawaiian
Other Pacific Islander
White or Caucasian
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Unknown Ethnicity
Preferred Contact Method
*
Text
Call
Email
Phone/Text Number
Email
example@example.com
INSURANCE INFORMATION
Insurance Coverage Name:
* If uninsured, include Driver's License # under Patient Information above
Insurance Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person Responsible:
Member Insurance ID:
Member Group ID:
SCREENING QUESTIONS
Have you experienced any of the following symptoms? (choose all that apply)
Muscle Aches
Sore Throat
Tiredness, Fatigue
Nausea & Vomiting
Cough
Headache
Diarrhea
Shortness of Breath
Other
Have you come into contact with anyone who has tested positive for the Coronavirus (COVID-19)?
*
Yes
Unknown
Have you traveled outside of Arizona in the last 21 days?
*
Yes
No
Date
-
Month
-
Day
Year
Date
Please review the Informed Consent for Coronavirus (COVID-19) Testing
Signature
*
Submit
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