1 Personal Information & Appointment2 Coronavirus (COVID-19) Testing Consent Name* First Middle Last Date of Birth* Date Format: MM slash DD slash YYYY Sex*MaleFemalePregnantYesNoUnknownRace*American Indian or Alaskan NativeAsianNative Hawaiian or Other Pacific IslanderBlack or AfricanWhiteOtherUnknownRefused to ReportEthnicity*Hispanic or LatinoNot Hispanic or Not LatinoUnknown Not ClassifiedRefused to AnswerStreet Address*City*State*County*ZIP / Postal Code*Cell Number*Email Address Enter Email Confirm Email Insurance NamePolicy Holder Name First Last Policy NumberService*COVID-19 Testing Appointment Date* January 2021 Sun Mon Tue Wed Thu Fri Sat 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January 28, 2021 11:15 AM 11:30 AM Please click on the time to set the appointment.Coronavirus (COVID-19) Testing Consent* I agree to the consent for Coronavirus (COVID-19) Testing. Informed Consent for Coronavirus (COVID-19) Testing I authorize the Macoupin County Public Health Department/Maple Street Clinic to conduct collection and testing for COVID-19 through a nasal swab or other CDC approved specimen collection method. I authorize my test results to be disclosed to the county, state, or any other governmental entity as may be required by law. I authorize the Macoupin County Public Health Department/Maple Street Clinic to release my COVID-19 test results to me by mail or my personal email as provided. I have been informed about the test purpose, procedures, possible benefits and risks. I have been given the opportunity to ask questions before I give my verbal consent, and I have been told that I can ask other questions at any time. I voluntarily agree to testing for COVID-19. Date Consent Obtained* Date Format: MM slash DD slash YYYY Not a Minor Consent I verify that I am not a minor and I am 18 years of age or older Guardian's Name* First Last Guardian's Date of Birth* Date Format: MM slash DD slash YYYY Results to Patient* Mail to the address Email Verbal Consent received by Macoupin County Public Health Department/Maple Street ClinicNameThis field is for validation purposes and should be left unchanged.