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• Parent DOB

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• Patient DoB

   

• *

• *

• English Spanish

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• COVID Testing Form

• Please complete one form for every person in your party. Para Espanol clic aqui

• Are you a member of the following groups: first responders, dispatchers, public works, teachers/school staff, or National Guard? *

  Yes No

• Please select the option which best reflects your employment

  Firefighter Police Officer Teacher/School Staff (Including Bus Drivers) Early Childhood Provider Dispatcher Public Works National Guard Paramedic EMT

• What town do you work for?

  Andover Ansonia Ashford Avon Barkhamsted Beacon Falls Berlin Bethany Bethel Bethlehem Bloomfield Bolton Borough of Bantam (Litchfield) Borough of Danielson Borough of Fenwick (Old Saybrook) Borough of Jewett City (Griswold) Borough of Litchfield Borough of Newtown Borough of Stonington Borough of Woodmont (Milford) Bozrah Branford Bridgeport Bridgewater Bristol Brookfield Brooklyn Burlington Canaan Canterbury Canton Chaplin Cheshire Chester Clinton Colchester Colebrook Columbia Cornwall Coventry Cromwell Danbury Darien Deep River Derby Durham East Granby East Haddam East Hampton East Hartford East Haven East Lyme East Windsor Eastford Easton Ellington Enfield Essex Fairfield Farmington Franklin Glastonbury Goshen Goshen - Woodridge Lake Sewer District Granby Greenwich Griswold Groton Guilford Haddam Hamden Hampton Hartford Hartland Harwinton Hebron Kent Killingly Killingworth Lebanon Ledyard Lisbon Litchfield Lyme Madison Manchester Mansfield Marlborough Meriden Meriden Second Middlebury Middlefield Middletown Middletown, City Fire Middletown, South Fire Middletown, Westfield Fire Milford Monroe Montville Morris Morris - Deer Island Assoc. Naugatuck New Britain New Britain - Downtown New Canaan New Canaan Sewer New Fairfield New Hartford New Haven New London New Milford Newington Newtown Norfolk North Branford North Canaan North Haven North Stonington Norwalk Norwich Old Lyme Old Saybrook Orange Oxford Plainfield Plainville Plymouth Pomfret Portland Preston Prospect Putnam Redding Ridgefield Rocky Hill Roxbury Salem Salisbury Scotland Seymour Sharon Shelton Sherman Simsbury Somers South Windsor Southbury Southington Sprague Stafford Stamford Sterling Sterling, Fire District Stonington Stratford Suffield Thomaston Thompson Tolland Torrington Trumbull Union Vernon Voluntown Wallingford Warren Washington Waterbury Waterford Watertown West Hartford West Haven Westbrook Weston Westport Wethersfield Willington Wilton Winchester Windham Windsor Windsor Locks Wolcott Woodbridge Woodbury Woodstock

• Are you an existing CHC patient or have you been tested at a CHC COVID Facility previously? *

  Yes No

• By checking the box and signing below, I acknowledge that I have read and understand the Informed Consent for COVID-19 Testing document and I further acknowledge that I have read and received a copy of CHC s Notice of Privacy Practices (NPP).
• By checking this box and signing my name below, I also consent to COVID-19 testing for me/my dependent and acknowledge that I agree to the statements contained in the Informed Consent for COVID-19 Testing document

• Consent for Testing *

  Consent for Testing *

• Please type the first and last name of Patient (or Parent/Guardian if Minor) to confirm consent *

• Your electronic signature

   

• Patient First Name *

• Patient Middle Name

• Patient Last Name *

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• Patient Birth Month *

  January February March April May June July August September October November December

• Patient Birth Day *

  01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

• Patient Birth Year *

  2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

• My Birth Date

   

• Is the date of birth above correct? *

  Yes No
• By providing my mobile or cellular number, I acknowledge the risks associated with receiving a text message as detailed in the Informed Consent for COVID-19 Testing document and, despite those risks, I request that results be delivered by text.

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• Primary/Mobile Phone Number for Results *

• Please confirm your primary/mobile phone number *

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• Patient Email *

• Please confirm your email *

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• Secondary/Home Phone Number

• Please confirm your home phone number

• Your Street Address *

• Street 2

• City *

• Zip Code *

• State *

  AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

• Sex *

  Male Female Other

• Race *

  Black or African American American Indian or Alaskan Native Asian White Native Hawaiian or Other Islander Declined Unspecified Other

• Race Other

• Ethnicity *

  Hispanic or Latino Non-Hispanic or Latino Declined Unspecified Other

• Ethnicity Other

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Parent/Guardian Information

• By checking this box, I agree to have my child tested for COVID

  By checking this box, I agree to have my child tested for COVID

• Parent First Name

• Parent Last Name

• Parent Phone

• Parent Email

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• Parent Birth Month

  January February March April May June July August September October November December

• Parent Birth Day

  01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

• Parent Birth Year

  2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

• If you are done with this form, please select Submit. If you would like to submit another form for another person, please select Next Patient.
  Please click the button once. You will be brought to a confirmation page upon submission.