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Patient Registration Form

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Please upload an image of your id or enter your drivers license number
[field id="first_name"]
[field id="last_name"]
[field id="pt_email"]
[field id="pt_street"]
[field id="pt_mobile"]
[field id="pt_gend"]
[field id="pt_race"]
[field id="pt_dob"]
[field id="sp_test"]
[field id="sp_collection_dt"]
[field id="paym"]
[field id="pt_insurance_p"]
[field id="pt_mem_id"]
[field id="pt_lic"]
[field id="speci_id"]
[field id="date"]
[field id="re_patient"]

Informed Consent for COVID-19 Testing

Please carefully read the following informed consent:
I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through anasopharyngeal swab, 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 governmental entity asmay be required by law.
I acknowledge that a positive test result is an indication that I must continue to self-isolate in an effortto avoid infecting others.
I understand that I am not creating a patient relationship with Knox Public Health by participating intesting. I understand the testing unit is not acting as my medical provider. Testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate action with regards to my test results. I agree 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 false positive or false negativetest results.
I, the undersigned, have been informed about the test purpose, procedures, possible benefits andrisks. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask other questions at any time. I voluntarily agree to testing for COVID-19.
[field id="first_name"]
[field id="last_name"]
[field id="pt_email"]
[field id="pt_street"]
[field id="pt_mobile"]
[field id="pt_gend"]
[field id="pt_race"]
[field id="pt_dob"]
[field id="sp_test"]
[field id="sp_collection_dt"]
[field id="paym"]
[field id="pt_insurance_p"]
[field id="pt_mem_id"]
[field id="pt_lic"]
[field id="speci_id"]
[field id="date"]
[field id="re_patient"]

Informed Screening for COVID-19 Testing

Due to the COVID-19 pandemic, and in an attempt to minimize the spread of the virus, Queen of Safety Supply Co. LLC is required to screen all youth, staff, and visitors participating in a youth day or overnight event. In order to be granted access to events, all visitors must truthfully complete and submit the following:
While at the event I will maintain a minimum of 6 feet of separation from any other individuals not within my household.
I have not in the past 7 days exhibited any of the known symptoms of COVID-19, including:
In the past 14 days I have not been in contact with any person known to have contracted COVID-19.
Although not required, I understand it is recommended that I wear a cloth face covering (over the nose and mouth), or non-medical grade face masks, if available. I also understand that it is recommended that I follow the minimum standard health protocols issued by the Texas Department of State Health Services and cited by the Texas Governor in his Executive Orders related to the pandemic.
I understand that the virus that causes COVID-19 can be spread to others by infected persons who have few or no symptoms. Even if an infected person is only mildly ill, the people they spread it to may become seriously ill or even die, especially if that person is 65 or older with pre-existing health conditions that place them at higher risk. Because of the hidden nature of this threat, everyone should rigorously follow the practices specified in the DSHS protocols, all of which facilitate a safe and measured reopening of Texas. The virus that causes COVID-19 is still circulating in our communities. We should continue to observe practices that protect everyone, including those who are most vulnerable.
I understand that Queen of Safety Supply Co. LLC cannot guarantee that I will not contract the virus, even when implementing screening protocols. I further understand that safety is a shared duty, COVID-19 is a shared risk, and all community members, including visitors, must take steps to promote health and safety. I acknowledge that I am assuming the riskthat I may contract the virus by entering facilities, even when screening protocols and mitigation measures are implemented.
I understand that Queen of Safety Supply Co. LLC is required to have this attestation in order for me to attend events sponsored by them and I sign below to confirm the truth of the above.
[field id="first_name"]
[field id="last_name"]
[field id="pt_email"]
[field id="pt_street"]
[field id="pt_mobile"]
[field id="pt_gend"]
[field id="pt_race"]
[field id="pt_dob"]
[field id="sp_test"]
[field id="sp_collection_dt"]
[field id="paym"]
[field id="pt_insurance_p"]
[field id="pt_mem_id"]
[field id="pt_lic"]
[field id="speci_id"]
[field id="date"]
[field id="re_patient"]