PCR Intake Form

authorize Voyage Medical to administer the SARS-CoV-2-RT-PCR test. I agree to the following protocols:

I understand that I will need to seek my own medical consultation for further information regarding my test results. I have received information on test limitations and understand that a negative test does not rule out past or future infection.

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I wish to have these results emailed to me.

I wish to pick up a hard copy and understand that this location closes at 5 pm.

Full Name:

Date of birth:

Age:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Passport Number:

Phone Number:

I authorize Voyage Medical to release the test results to the following e-mail:

Signature

Date:

A negative test does not prove that you are 100% negative. All State and Federal mandates for social distancing and self-quarantine while not performing essential work duties should be strictly followed.
If your test is positive, please contact your medical provider for further instructions and care. Your state department of health will be notified of your positive results.

OFFICE USE ONLY

Specimen source:

Time

Fact Sheet for Recipients CDC Handouts given to client.

Notes:

Provider Signature:

Date

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PCR Intake Form

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