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Patient Registration

Please enter all information accurately as possible.


This form is secure and HIPAA-compliant .

Patient In-Take Form
Personal Information:
Insurance Information:
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Patient Consent

By checking the general consent box below, I certify that I consent for Phosphorus to perform the test(s) ordered by the authorizing provider. I acknowledge that I am the patient providing the sample or the parent/guardian of the child providing the sample, and I am either (1) at least 18 years of age or (2) I am legally recognized as an ‘emancipated minor’ by the state in which I reside. 


I hereby authorize Everpoint Medical, PLLC and Phosphorus to release the result of my COVID-19 test to Ethical Culture Fieldston School. The purpose of this disclosure is to provide information to the above listed individual/entity for infectious disease management. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient(s) and may no longer be protected by HIPAA Privacy regulations. I understand that I may refuse to sign this authorization; and that my refusal to sign in no way affects my treatment, payment, enrollment in a health plan, or eligibility for benefits except if the purpose of such test is to create information for disclosure such as an employment physical or independent medical exam.

You have been registered!

You will receive an email confirmation shortly.

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