Combest COVID Community Testing
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Testing Request
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If you require testing for multiple persons please submit a request for each person in question
Patient Information
Last Name
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First Name
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MI
Patient DOB
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Sex
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F
M
Phone #
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Area code is required
Address
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City
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State
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Alabama
Alaska
American Samoa
Arizona
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California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
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New York
North Carolina
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Northern Marianas Islands
Ohio
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Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
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County
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Race
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American Indian / Alaskan Native
Asian
Black or African American
Native Hawaiian / Pacific Islander
Other
Unknown
White
Race Other
Ethnicity
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Hispanic
Non-Hispanic
Unknown
Patient Type
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Inpatient
Outbreak association (specify)
Outpatient
Outbreak association
Pregnant
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No or N/A
Unknown
Yes
Do you live in a setting with more than 3 family members or friends?
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Yes
No
Explain who lives in your household
Consent Details
Authorization and Consent for Covid-19 Diagnostic Testing:
I voluntarily consent and authorize Texas Tech University Health Sciences Center (TTUHSC) to conduct COVID-19 diagnostic testing.
I acknowledge and understand that TTUHSC staff will collect an appropriate sample through a nasopharyngeal swab, oral swab, or other recommended collection procedures.
I understand that the sample will be tested for COVID-19 and there may be a potential risk for false positive or false negative test results.
I acknowledge that a positive test result is an indication that I must continue to self-isolate in an effort to avoid infecting others.
Should I have question or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider.
I understand that there may be a cost associated with this COVID-19 test.
I acknowledge that I have been provided a copy of TTUHSC’s Notice of Privacy Practices, which describe how TTUHSC may use and disclose your protected health information to carry out treatment, initiate and obtain payment, conduct health care operations and for other purposes that are permitted or required by law
I acknowledge and agree that TTUHSC may disclose my test results and associated information to appropriate county, state, or other governmental and regulatory entities as may be permitted by law.
TTUHSC Privacy Practices
NOTICE OF PRIVACY PRACTICES
AVISO DE PRÁCTICAS DE PRIVACIDAD
Relationship to Patient
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Patient
Guardian
Please correct the following issues prior to submitting your request:
Last Name is required
First Name is required
Patient DOB is required
Sex is required
Phone # is required
Address is required
City is required
Zip is required
Race is required
Ethnicity is required
Pregnant is required
Congregate setting is required
Relationship to Patient is required
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