COVID Survey 3.0
Patient #
of
in vehicle
Last Name
First Name
Middle Name
Email
Phone
Ordering Provider
Ordered Via
Paper
Fax
Other
No Order
Patient is same as photo ID
Birthdate
Male
Female
Guardian/Name on Photo Id
Address on photo ID is current
Current Address
,
Reason for Testing:
Symptomatic (Cough, Chest Congestion, Fever, etc)
Preprodecural Screening
Upcoming Travel
Contact or Exposure w/ Known Positive Case
Other Work/School/Sport Screening
Notes