Spence's Medical Center Pharmacy COVID-19 & Flu Testing Consent/Triage Form

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Please fill out this form to the best of your knowledge so that we may confirm your eligibility to receive COVID-19 testing and to document health and demographic information required by Texas DSHS for COVID-19 test results reporting.

First Name *

Last Name *

Date of Birth *

YYYY

Age *

Sex *

Male

Female

Other

Unknown

Ambiguous

Ethnicity (select only one) *

Hispanic or Latino

Not Hispanic or Latino

Unknown/Patient refused

Required

Regardless of how you answered the prior question, please indicate which of the following best describes your racial identity (Select all that apply). *

American Indian or Alaska Native

Asian

Black or African-American

Native American or Other Pacific Islander

White

Other

Unknown/Patient Refused

Required

Address (must include street name or PO Box) *

City *

State Abbreviation (EX: Texas = TX) *

ZIP code *

Phone Number *

Email *

Credit Card Number (only required if not paying cash)

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