Old Man Covid19 Swab/Registration Request Name* First Last Date of birth* MM slash DD slash YYYY Home address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 PaymentThe payer for this test is Old Man Inc.ResultsWould you like us to text you or email you your results?Please text my results to:Please email my results to: 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.* Yes No IF YES: Name of employer. 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
