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

Tyler, TX Plano, TX

Patient Name *

First Name

Last Name

Address *

City

State

ZIP Code

Date of Birth *

Gender *

Male Female

Email Address

Phone Number *

If you wish to receive any information or promotions from Express Health Systems: *

No Thank You Email Text (carrier charges may apply) Mail

Patient Signature *

[clear]

Use your mouse or finger to draw your signature above

I am 18 years of age or older *

Yes No

Consent to treat minor children

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.

Guardian's Signature *