Date of Birth *

Sex *

Male

Female

Prefer not to say

State ID # (or Driver's License #)

and/or

Social Security #

REQUIRED: State ID # and/or Social Security # for ALL patients above the age of 15. SSN required for those 15 and under.

Upload a Picture of the FRONT of your Driver's License

Mobile Phone *

Email *

Address *

City *

State *

Zip Code *

Country *

Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Unknown

Other

Have you been in close contact with someone who tested positive for COVID-19 in the last 2 weeks? *

Yes

No

I don't know

If yes, when were you exposed?

Testing should not be performed until 5 days after exposure.

Do you have Health Insurance? *

Yes

No

For Self Pay, Select "NO"

Is this insurance your own or through a spouse/other? Select one of the following: *

Self

Spouse

Upload a Picture of the FRONT of your Insurance Card *

Upload a Picture of the FRONT of your Insurance Card

Upload a Picture of the BACK of your Insurance Card *

Upload a Picture of the BACK of your Insurance Card

Insurance Group Number *

Insurance ID Number *

Guarantor's Name

Guarantor's Date of Birth

Secondary Insurance Group Number

Secondary Insurance ID Number

Secondary Insurance Guarantor's Name

Secondary Insurance Guarantor's Date of Birth

HIPAA Consent

I understand that as part of my healthcare, this Practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. By clicking 'accept' you agree to the terms of the HIPAA Privacy Rule of Patient Authorization Agreement. I also give my permission to release my test results to other healthcare providers. *

I accept

I do not accept

Informed Consent

Please carefully read and indicate acceptance of the following Informed Consent: I (or legal guardian for minors) authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a saliva sample or blood sample, as ordered by an authorized medical provider or public health official. I authorize my test results to be disclosed to the county, state, or to any other government entity as may be required by law. I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others. I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree that I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. Release: To the fullest extent permitted by law, I hereby release, discharge and hold harmless, Utah Pain & Rehab, including, without limitation, any of its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results. I have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I click Accept, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.

Sign Below *

Clear