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Collection Date & Time
|
Please check if applicable
• • •
|
|
Insurance
|
Picture of specimen
|
|
Director/Company
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Event/Location
|
|
Technician
|
Government Issued ID #
|
|
Upload Image of ID
|
Sample Type
|
|
CDC Information
|
|
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Reason for visit
|
Symptoms
• • •
|
|
First Test
|
Employed with healthcare
|
|
Hospitalized
|
Symptomatic as defined by CDC
|
|
ICU
|
Resident in a congregate care setting (Care homes, Nursing homes etc.)
|
|
Pregnant
|
|
|
DJR Wellness Clinic COVID-19 TESTING WAIVER
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|
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Acknowledgement for uninsured testing
|
Acknowledgement for insurance benefits
|
