Mako Medical

Register for Testing

Location: AFFINIA HEALTHCARE

1717 BIDDLE ST, ST LOUIS MO 63106, US

Jan. 5, 2021 & Jan. 7, 2021 & Jan. 12, 2021 & Jan. 14, 2021 & Jan. 19, 2021 & Jan. 21, 2021 12PM - 3PM

Patient Information

First Name

Middle

Last Name

DOB

Sex

Race

Ethnicity

Phone Number

Address

Address 2

City

State

Zip Code

Missouri State Required Questions

1. Is this the first COVID19 test you've had?

Yes No Unknown

2. Are you currently employed in healthcare?

Yes No Unknown

3. Hospitalized?

Yes No Unknown

4. ICU?

Yes No Unknown

5. Resident in a congregate care setting (including nursing homes, residential care for people with intellectual and developmental disabilities, psychiatric treatment facilities, group homes, board and care homes, homeless shelter, foster care or other setting):

Yes No Unknown

6. Are you currently pregnant?

Yes No N/A

7. Symptomatic as defined by CDC?

According to the CDC:
People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

Yes No Unknown

Date of Symptom Onset:

Check the box next to each symptom you are experiencing. If you're experiencing any of these symptoms, you need to self-isolate while awaiting your test results:

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

8. I am a Missouri resident or a student currently residing in Missouri

Yes No

9. I understand that this test will require a swab being put about a half an inch into my nose

Yes No

Please review the following documents.
(1) HIPAA Authorization Form
(2) Informed Consent Form
By signing below, I acknowledge that I have read, understand and consent to all the details in the HIPAA Authorization and Informed Consent

Please draw your signature with mouse or finger to confirm your statements above are true and accurate.