Covid-19 Testing (Choice Films) Name* First Last Date of birth* MM slash DD slash YYYY Home address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone Number*Why are you having the Covid Swab test?* Sick Pre- surgical screening Repeat swab Return to work clearance School Travel Your DoctorDo you need these results faxed to your doctor’s office?* Yes No If yes, please provide:Doctor’s Name Fax NumberResultsWould you like us to text you or email you your results?Please text my results to:Please email my results to: Insurance InformationInsurance company* Insurance ID #* ConsentIf you wish the results to be sent to your employer or school, please authorize the release belowI hereby give consent for Middletown Medical, P.C. to release the results of my Covid-19 test to my Employer or School.* Yes No IF YES: Name of employer or school. Consent* I understand by completing this form and submitting my personal health information that I am requesting a consultation for a prescription for an anti-body test for Covid-19. Also, I understand by entering my information online, I consent to the blood draw and the TMV which involves us obtaining your medication history and demographics and that we will bill your insurance company for the visit and the lab test.CAPTCHA
