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COVID-19 Specimen Intake Form - wp sbcounty 2026
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- Click ‘Get Form’ to open the COVID-19 Specimen Intake Form in the editor.
- Begin by filling out the 'Patient Details' section. Enter the MRN, full name, age, address, and primary phone number. If applicable, check the box for 'Homeless' and indicate if the patient is pregnant.
- Provide additional information such as gender, date of birth, primary language, occupation, and height and weight. Ensure all fields are completed accurately.
- In the 'Clinical Details' section, mark any symptoms the patient is experiencing. Indicate if they are currently hospitalized or in an ICU setting.
- Complete the 'Exposures' section by answering questions about recent travel and contact with confirmed cases of COVID-19.
- Fill out the 'Other Testing' section by indicating any tests performed and their results. Be thorough to ensure accurate reporting.
- Finally, provide details for the submitting physician including their name, facility name, mailing address, phone number, fax number, and NPI#.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2020 | 4.8 Satisfied (167 Votes) |
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Mar 10, 2020 Please fax completed form and attach clinical notes and any lab tests used for diagnosis and/or follow up to 909-387-6377. at (800) 722-4794
by M Abril 2025 This indicates that the faculty participant received DE training at some point before the time the intake form was completed. Table 3.6Read more