* You must submit this form at least 48h ahead of your testing appointment.

COVID-19 TESTING/RESEARCH

Date:

Name:

DOB:

Gender:

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Phone Number:

Email:

Allergies:

Symptoms:

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Were you Previously Tested for Covid-19?

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If so, did your test results show:

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On Set of Symptoms:

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Social:

Smoker:

Alcohol Drinker:

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Medical History:

Race:

*** If you are under 18 years old these consents must be signed by a parent or legal guardian.

I verify the information provided on this document is true and accurate to the best of my knowledge

Donor's Signature:

I give Xera Med Research authorization to provide my test results electronically to my email

I have read the informed consent. I freely and voluntarily consent to Xera Med’s Research for COVID-19 testing/research.

*** If you are under 18 years old these consents must be signed by a parent or legal guardian.