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Covid19 Patient Registration

EXPRESS HEALTH SYSTEMS

Covid19 Patient Registration

Covid19 Patient Registration Form

New and existing Patients must complete this form for Covid19 Evaluation/Testing.

What location would you like to have your Covid19 test collected at: * *Currently available in Texas only
Patient Name *
Date of Birth *
Gender *
If you wish to receive any information or promotions from Express Health Systems: *

Medical History

Current/Past Medical History - Check all that apply: *
Heart Attack Date *
Stroke Date *
Past Surgical History - Check all that apply: *
Social History - Check all that apply: *
Acknowledgement: *
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I am 18 years of age or older *

By signing below, I do hereby consent to any medical care and/or treatment administered by the clinician(s) at Express Health Systems (EXPHS). I understand that EWLC, as well as other clinicians, cannot anticipate whether my child will experience adverse reactions, side effects, or allergic reactions, after receiving any medication(s) EWLC prescribes or administers via injections. I understand that such reactions can occur to anyone, with any medication, at any time, and that the prescribing clinician and EWLC is not at fault for such reactions. I understand that if my child experiences any adverse reactions, side effects, or allergic reactions from any medication(s) that they receive from EWLC, then it is my responsibility to discontinue my child's use of the medication immediately, seek advice, and to have my child evaluated by their PCP and/or Emergency Medical Providers. In the event that my child experiences a medical emergency while being treated at EWLC, I consent to the administration of medical life saving measures determined by the clinician to be necessary for the welfare of my child, while waiting for Emergency Medical Services to arrive on scene during said emergency.

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Guardian's Printed Name *