New Patient Enrollment
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Sex
*
Please Select
Male
Female
N/A
Phone Number
*
-
Country Code
-
Area Code
Phone Number
E-mail
*
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Taking any medications, currently?
*
Yes
No
Please list it here
In case of emergency
Emergency Contact:
*
First Name
Last Name
Relationship
Contact Number
*
Type of Test
*
Appointment
*
HIV/STD Testing Consent Acknowledgment
*
Consent to HIV/STD Testing I acknowledge that I have received information about HIV and STD testing, including the purpose, benefits, and potential risks. I understand that my test results will be kept confidential as required by Florida law. I voluntarily consent to be tested for HIV and/or sexually transmitted infections. I understand that I may withdraw this consent at any time before the test is performed.
COVID-19 Testing Consent Acknowledgment
*
I understand that this test is used to detect the presence of COVID-19. I consent to be tested and acknowledge that I have received basic information about the procedure and its purpose.
Flu A/B Rapid Test
*
General Consent for Routine Testing I consent to routine diagnostic testing as recommended by the provider. I understand the purpose of these tests and agree to proceed.
Drug Testing Consent Acknowledgment
*
I consent to provide a urine sample for drug screening purposes. I understand that this test is designed to detect the presence of substances including, but not limited to, marijuana, cocaine, amphetamines, opioids, and benzodiazepines. I acknowledge that the results may be used for diagnostic, employment, or legal purposes, and that confirmatory testing may be required. I understand that my results will be handled confidentially and in accordance with applicable laws and regulations.
Pregnancy Test Consent Acknowledgment
*
I consent to receive a pregnancy test. I understand that this test detects the presence of the hCG hormone and may be conducted via urine. I acknowledge that the results will be shared with me confidentially and that confirmatory testing may be recommended.
Hemoglobin A1c Consent Acknowledgment
*
I consent to a Hemoglobin A1c test to evaluate my average blood glucose levels over the past 2–3 months. I understand that this test is used to monitor diabetes and guide treatment decisions. I acknowledge that results will be discussed with me and kept confidential.
RSV Test Consent Acknowledgment
*
I consent to receive a test for respiratory syncytial virus (RSV). I understand that this test may involve a nasal swab and is used to detect active infection. I acknowledge that results will be used to guide treatment and will be kept confidential.
TB (Tuberculosis) Test Consent Acknowledgment
*
I consent to a tuberculosis screening test, which may include a skin test (PPD) or blood test. I understand the purpose of this test and that follow-up may be required depending on the results. I acknowledge that results will be shared with me confidentially.
Submit
Submit
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