Express Health Systems

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COVID-19 Patient Registration Form

EXPRESS HEALTH SYSTEMS

COVID-19 Patient Registration

COVID-19 Patient Registration Form

Covid-19 Testing is only offered at our Tyler, TX office.

New and existing Patients must complete this form for COVID-19 Evaluation/Testing.

Patient Name *
Date of Birth
Gender *
If you wish to receive any information or promotions from Express Weight Loss Clinic:
History of Present Illness (HPI)
Why are you seeking COVID-19 evaluation and testing?
True
T
False
F
SUBJECTIVE: Exposure, Specific History
Yes
Y
No
N
Fever or Chills?
Cough?
Shortness of Breath/Difficulty Breathing?
Fatigue?
Muscle or Body Aches?
Headache?
New Loss of Taste or Smell?
Sore Throat?
Congestion?
Runny Nose?
Nausea or Vomiting?
Diarrhea?
Acknowledgement:
Use your mouse or finger to draw your signature above
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 Weight Loss Clinic (EWLC). 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.

Use your mouse or finger to draw your signature above
Guardian's Printed Name *
Please upload a picture of the front of your driver's license.
Please upload a picture of the front and back of your insurance card.
Please provide us with a description of your vehicle so we can find you easier.
Please select your payment type: *

Payment Information

Enter your card information: *
What is your ethnicity: