General Patient Intake Form

*Please fill out a different form for each individual getting a test.

Patient Name(Required)

Patient or Parent/Guardian Photo ID Upload (Copy of Driver's License, State ID, or Passport)

Drop files here or
Max. file size: 32 MB.
    Drop files here or
    Max. file size: 32 MB.

      Consent for Direct Access Results

      I, First Name Last Name, hereby authorize NJ Covid to release results of tests associated with this request, that includes protected health information, directly to myself (or legal guardian, if indicated) via the Method of Results Release chosen below. This authorization will remain in effect until the request is fulfilled by NJ Covid and no longer. Myself or my physician may contact NJ Covid for all other requests for test results release not associated with this test requisition.

      I understand that my healthcare provider, and not NJ Covid, is responsible for consulting with me on all test results.

      I understand that signing this form is voluntary and that if I don’t sign, it will not affect the commencement, continuation or quality of services. If I change my mind, I understand that I can revoke this authorization by providing a written notice of revocation. The revocation will be effective immediately upon the laboratory's receipt of my written notice, except that the revocation will not have any effect on any action taken by the laboratory in reliance on this Authorization before it received my written notice of revocation.

      If patient is a minor or is unable to sign this Authorization, Parent/Guardian please complete the information below: