Healthcare Covid-19 Response Form

HEALTHCARE COVID-19 RESPONSE FORM

Purpose: This form documents patient screening, exposure, vaccination and testing consent related to SARS-CoV-2 (COVID-19). Information provided is required for clinical assessment, infection control, public health reporting, and billing. By completing and signing, the patient certifies that the information is true and authorizes limited disclosures as described below.

Patient Information

Date of Birth:    Gender: Male   Female   Other

Emergency Contact

Insurance Information

Medical History (relevant to COVID-19)

COVID-19 Screening

Date of Screening:

Symptoms in the past 14 days (check all that apply):

Fever or chills   Cough   Shortness of breath or difficulty breathing   Fatigue

Muscle or body aches   Headache   New loss of taste or smell   Sore throat

Known exposure to a confirmed COVID-19 case in the past 14 days: Yes   No

If yes, date of exposure:

Travel outside the local area in the past 14 days: Yes   No

Testing and Vaccination

Prior COVID-19 positive test: Yes   No

If prior positive, date of most recent positive test:

COVID-19 vaccination status: Vaccinated   Not Vaccinated

Clinical Consent and Acknowledgments

Consent to COVID-19 testing: I consent to collection of specimens for COVID-19 testing, including but not limited to nasal, nasopharyngeal, or saliva swab specimens. I understand the nature of the test, potential discomfort, and that no test is 100% accurate. I authorize the clinical staff to perform testing as indicated.

Authorization to disclose test results: I authorize the release of my COVID-19 test results and relevant health information to public health authorities, my identified emergency contact, my health insurance carrier for billing, and other healthcare providers for the purposes of treatment, infection control, and public health reporting as required by law.

Requirement to isolate/quarantine: If I receive a positive result or am directed by clinical staff or public health officials to isolate or quarantine, I agree to follow instructions and acknowledge that failure to comply may present risk to others.

Accuracy and penalties: I certify that the information given on this form is true and complete to the best of my knowledge. I understand that intentionally providing false information may have legal or civil consequences.

Attestation

By signing below I attest under penalty of perjury that the foregoing responses are accurate and complete, I consent to testing and to the disclosures described above, and I acknowledge receipt of COVID-19 privacy and notification practices applicable to this clinic.

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