* You must submit this form at least 2h ahead of your testing appointment.
COVID-19 TESTING/RESEARCH
Date:
Name:
DOB:
Gender:
Phone Number:
Email:
Allergies:
Symptoms:
Were you Previously Tested for Covid-19?
If so, did your test results show:
On Set of Symptoms:
Social:
Smoker:
Alcohol Drinker:
Medical History:
Race:
*** If you are under 18 years old these consents must be signed by a parent or legal guardian.
I verify the information provided on this document is true and accurate to the best of my knowledge
Donor's Signature:
I give Xera Med Research authorization to provide my test results electronically to my email
I have read the informed consent. I freely and voluntarily consent to Xera Med’s Research for COVID-19 testing/research.
*** If you are under 18 years old these consents must be signed by a parent or legal guardian.
Please fill all the fields with correct values.