Antibody Intake Form

Legal Name*

First Last

Referred By

Employer Name

Date*

Date of Birth*

Sex

Male
Female

Height

Feet

Inches

Weight

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

Allergies*

Latex
Alcohol
Other
None

If Other Allergies selected ( Please list)

Emergency Contact Phone Number

Has the patient had contact with a confirmed or suspected COVID-19 case within last 14 days?*

Yes
No

Within the last 14 days, have you been experiencing any of the following*

Fever
Chills
Cough
Shortness of Breath
None
Other

If Other, please specify

Has the patient had contact with anyone with an unexplained respiratory illness within last 14 days?*

Yes
No

Relevant Past Medical History/Risk Factors

Asthma/Pulmonary Condition*

Yes
No

Hypertension/Cardiac Disease*

Yes
No

Hyperlipidemia*

Yes
No

Digestive*

Yes
No

Diabetes*

Yes
No

Auto Immune Conditions*

Yes
No

Osteoarthritis*

Yes
No

Muscle Pain or Cramps*

Yes
No

Joint Pain Stiffness/Swelling*

Yes
No

Back/Neck Pain*

Yes
No

Anxiety*

Yes
No

Insomnia*

Yes
No

Depression*

Yes
No

COVID-19 ANTIBODY CONSENT*

I understand that this test looks for antibodies to COVID-19, NOT the virus itself. Testing for viral DNA, via PCR analysis, is performed only in specifically designated places and on patients who meet a strict pre-test criteria. I am electing to have this antibody test to assess whether or not I have been exposed to the novel coronavirus in the past. I additionally understand that if I choose to have this test fewer than seven days after the resolution of symptoms, the results may be less reliable. I hereby attest that I have been advised to take this test only as a completely asymptomatic individual. I have never had symptoms or at least have been symptom-free for seven days. I also understand that the results of this test may be given to the department of health or CDC for their statistical and demographic value. Once I am given my results for this test, I understand that they are only a preliminary measure of IgG/IgM antibodies (qualitative measure) and that the values of antibodies (quantitative measures) may vary. This test does not guarantee immunity to COVID-19 or any other virus.

Patient's Name*

Patient's Signature*

Date

Antibody Intake Form

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