Surveypoint

Q1

Name

First Name

Q2

Name

Last Name

Q3

Age

Q4

Date of Birth

Date

Q5

Gender

Male

Female

Q6

Phone Number

Q7

Email

Q8

Address

Street Address

Q9

Address

Street Address Line 2

Q10

Address

City

Q11

Address

State / Province

Q12

Address

Postal / Zip Code

Q13

Occupation

Q14

Company Name

Q15

SSN

Q16

Emergency Contact Person

First Name

Q17

Emergency Contact Person

Last Name

Q18

Emergency Contact Phone

Q19

Do you have an insurance coverage?

Yes

No

Q20

Reason for testing

Experiencing COVID-19 Symptoms

Work requirement

Exposure

Travel

Other

Q21

Weight (kg)

Q22

Height (cm)

Q23

Temperature F

Q24

Blood Pressure

Q25

Heart/Pulse Rate

Q26

Do you have any allergies?

Yes

No

Q27

Are you currently taking any medications?

Yes

No

Q28

Are you experiencing the following symptoms?

Present

Not Present

Remarks/Notes

Difficulty of breathing

Coughing

Conjunctivitis

Fever

Loss of taste

Loss of smell

Diarrhea

Headache

Body weakness

Q29

Method of Payment

Cash

Credit Card

Check

Wire Transfer

Bank Payment

PayPal

Q30

Patient Signature

Q31

Date Signed

Date

New Patient Covid Registration -Form Fill

Name

Name

Age

Date of Birth

Gender

Phone Number

Email

Address

Address

Address

Address

Address

Occupation

Company Name

SSN

Emergency Contact Person

Emergency Contact Person

Emergency Contact Phone

Do you have an insurance coverage?

Reason for testing

Weight (kg)

Height (cm)

Temperature F

Blood Pressure

Heart/Pulse Rate

Do you have any allergies?

Are you currently taking any medications?

Are you experiencing the following symptoms?

Method of Payment

Patient Signature

Date Signed