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COVID-19 Testing Registration Form
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* Indicates required question
First and Last Name
*
Your answer
Birth Gender
*
M
F
Preferred Language
Your answer
Are you a veteran?
Y
N
Clear selection
Insurance Information
Insurance
Your answer
Insurance ID#
Your answer
Insurance Group #
Your answer
Insurance Holder
Your answer
Holder's DOB
MM
/
DD
/
YYYY
If uninsured, list ID # for one of the ID types below (pick one)
Driver's License
Social Security
State ID
Employee # (only if no other ID available)
Military ID
Clear selection
ID#
Your answer
Family/Support Information
Emergency Contact
Your answer
Relationship
Your answer
Phone Number
Your answer
Race/ Ethnicity
Check the box that best describes your race and Ethnicity
Race
*
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian
Other Pacific Islander
White
More Than One Group
Decline to specify
Ethnicity
*
Latino or Hispanic
Not Latino or Hispanic
Decline to specify
Housing Status
Check any box that describes your current housing situation
Doubling Up (living with extended family, friends, or acquaintances)
Not Homeless (legally occupied, single family, owned or rented)
Street (on the street, in cars, abandoned buildings, under bridge)
Transitional (treatment program, hospital, jail, motel)
Shelter
Unknown/Unreported
Other:
Do you live in a group setting like an Adult Foster Care or senior community?
Yes
No
Unsure
Clear selection
Consent
*
I consent to the following:
Required
• Receiving testing and/or services by Cherry Health
• Cherry Health ordering labs/testing
• Billing insurance for care provided
• Communicating results of testing with your employer for all employer required tests
• Communicating test results to shelter / housing coordinators if accessing group living
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