Mobile COVID-19 Test Form Name * Name First First Last Last Phone * Email * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Date of Birth * Test Type * Antigen Rapid testAntibodyPCR Date * Time * 8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM5:00 PM5:30 PM6:00 PM File Upload * Upload Driver's License / ID or Passport for Verification Choose File Maximum upload size: 314.57MB Patient Covid-19 Screening Questionnaire Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.) Fever (100.4° F/37.8° C or greater as measured by an oral thermometer) * Yes No Cough * Yes No Shortness of breath or difficulty breathing * Yes No New loss of taste or smell * Yes No Chills * Yes No Head or muscle aches * Yes No Nausea, diarrhea, vomiting * Yes No In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? * Yes No In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? * Yes No Traveled in the last 14 days? * Yes No Disclaimer: I (myself, my child, or a minor under my legal care) voluntarily consent and authorize Mobile COVID Testing Houston to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test. I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample by a nasal or oral swab. I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and there may be a potential for false positive or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have question or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider. Release of Information and Assignment of Benefits: I authorize Mobile COVID Testing Houston to release information from my medical record to any healthcare provider participating in any way in the care of the patient and to any person or entity which is or may be liable for all or part of the charges for services received. In addition, I authorize my insurance benefits be paid directly to Mobile COVID Testing Houston I also understand that following release of medical records or information, Mobile COVID Testing Houston will no longer be responsible for the confidentiality of any documents released in accordance with this authorization. I understand that by written notice to Mobile COVID Testing Houston I may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon it. Signature reCAPTCHA If you are human, leave this field blank. Submit
