Get the free COVID-19 Intake Form - Sussex County

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Dose: 1st 2nd 3rdMedley Pharmacy, Inc COVID-19 Vaccine Former Clinic Use: Patient\'s Full Name: ___ Date of Birth: ___Age: ___Date: Time:Administer: (circle one) Moderna: 0.25 mL 0.5 mL Pfizer: 0.2mL

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How to fill out covid-19 intake form

01

Start by providing your personal information such as name, date of birth, and contact details.

02

Answer questions about your current health status including any symptoms you may be experiencing.

03

Declare any recent travel history or close contact with someone who has tested positive for COVID-19.

04

Acknowledge and agree to consent for testing and treatment if necessary.

05

Review and submit the form as instructed.

Who needs covid-19 intake form?

01

Anyone who is seeking medical attention or testing related to COVID-19 may need to fill out a COVID-19 intake form.

02

This includes individuals who suspect they may have been exposed to the virus, or are experiencing symptoms such as fever, cough, and shortness of breath.

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What is covid-19 intake form?

Covid-19 intake form is a form used to collect information about individuals potentially affected by Covid-19.

Who is required to file covid-19 intake form?

Individuals who are potentially affected by Covid-19 or those seeking medical assistance for Covid-19 are required to file the form.

How to fill out covid-19 intake form?

The form can be filled out online or in person by providing accurate information about symptoms, medical history, and exposure to Covid-19.

What is the purpose of covid-19 intake form?

The purpose of covid-19 intake form is to gather necessary information for healthcare professionals to assess and provide appropriate care for individuals potentially affected by Covid-19.

What information must be reported on covid-19 intake form?

Information such as symptoms, travel history, exposure to Covid-19, and contact details must be reported on the covid-19 intake form.

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