PCHS Demographic Form

PCHS will be providing Covid Testing. 

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* 1. Please select the school/sport for your child:

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* 2. Last Name

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* 3. First Name

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* 4. Date of Birth

Date

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* 5. Sex at Birth

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* 6. Address

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* 7. Consent to Call

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* 8. Text Message ok?

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* 9. Insurance

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* 10. If uninsured and you would like to be contacted about how to apply for slide scale or insurance, please check the box.

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* 11. Billing Authorization
Please read the statements below. Check each box (last box for Medicare recipients only)
Enter your name and date to provide authorization.

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* 12. Name

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* 13. Date 

Date

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* 14. Select the box below if you would like to receive a copy of the Patient Rights and Responsibilities

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* 15. Select the box below to consent to Covid testing.

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