QUESTIONNAIRE – El Paso

Name**
Select date MM slash DD slash YYYY
Address*
Select an option*
2. Have you traveled in the past 10 days?
3. Have you experienced any COVID-19 symptoms or had been ill within the past 10 days?
CDC Symptoms
Or at least 2 of these symptoms
4. Have you lived or been in close contact with someone that has been diagnosed with COVID-19 within the past 10-days?
5. Do you agree to take temperature at the time of appointment?
6. Do you agree to wear your mask during the appointment?
, attest that the information provided in this form is accurate and true to the best of my knowledge. I understand that (Print first and last name) knowingly making a false statement on this form is a crime and can be punished by fine or imprisonment or both (HRS§ 710-1063).
Clear Signature

PATIENT RECORD FORM

MM slash DD slash YYYY
Sex:
Name
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MM slash DD slash YYYY
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Data added automatically, please update if required.
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ID Type (SSN, State ID, No ID, Foreign ID)*

**SELECT IF NO INSURANCE**

Location:
This schedule will be filed under the location selected above.
Reason for Testing
SERVICES PERFORMED
COVID TEST
Laboratory Results
Test Name
Result
Lot Number
 
no action required