COVID Test Data Points Form | staffingetc

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Call us today at 301-403-8838

For COVID Testing, call 833-333-0711

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Attendant with a Clipboard

Woman Getting Tested

Please fill out the information below to complete registration for your COVID Test.

First Name

Last Name

Test Ordered

Client Age

Today's Date

Client Date of Birth

Client Race

Ethnicity

Client Sex

Address

County of Residence

Zip Code

Phone

Email

Is this the client's first test?

Is the client employed in healthcare?

Is the client symptomatic?

Is the client living in a congregatedcare living setting?

Is the client pregnant?

Call us today at 301-403-8838

For COVID Testing, call 833-333-0711

9410 Annapolis Road Suite 200

Lanham, MD 20706

Phone: (301) 403-8838 (Main Office)

1997 Annapolis Exchange Parkway

Annapolis, MD

© 2017 by Innate Scribes

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