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COVID Testing Form
Please complete one form for every person in your party.
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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 Last Name
*
Patient Birth Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Patient Birth Day
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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
*
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
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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
.
Primary/Mobile Phone Number for Results
*
Please confirm your primary/mobile phone number
*
Patient Email
*
Please confirm your email
*
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
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
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.
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