POC COVID/FLU/STREP

POINT OF CARE TESTING for

COVID - FLU A/B - STREP

Patient Intake and Assessment Form

515 Inman Avenue, Colonia, NJ 07067
Patient Name*
Gender*

MaleFemale
Birth Date*

MonthDayYear
Address*

Patient Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Patient Phone Number*
Patient Weight
Primary Care Physician
Physician Phone Number
Please enter a valid phone number.
Medication Allergies
Current Medications
Current Situation When did your symptoms start?
Which of these symptoms do you currently have?
Fever?*

YesNo
What temperature?
Cough?*

YesNo
Vomiting?*

YesNo
Diarrhea?*

YesNo
Shortness of Breath?*

YesNo
Chills?*

YesNo
Sore Throat?*

YesNo
Muscle Pain?*

YesNo
New loss of Taste or Smell?*

YesNo
Have you taken any medications for these symptoms?*

YesNo
If yes, what have you taken, and when?
Do you have any of the following medical conditions?

Asthma or Chronic Lung DiseaseSerious Heart Condition, such as Congestive Heart FailureDiseases or conditions that make it harder to coughKidney Failure or End Stage Renal DiseaseConditions that result in a weakened immune system, including Cancer treatmentsDiabetesPregnancyExtreme ObesityCirrhosis

PLEASE CHOOSE TEST PREFERENCE BELOW:*

COVID & FLU COMBO swab

$35.00 Quantity

STREP swab

$11.00 Quantity

Total

$0.00