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WELCOME TO EVERPOINT

Greenwich Country Day School
Faculty Patient Registration

Date: March 26th

Please enter all information accurately as possible.

This form is secure and HIPAA-compliant .

Patient In-Take Form

Personal Information:

First Name

Last Name:

Email:

Sex:

Street Address:

City:

State:

Zip Code:

Contact Number:

Date of Birth:

Insurance Information:

Do you have insurance?

No

Yes

Insurance Company:

Member ID or Policy number:

Group ID number:

Policy holder's full name:

Relationship to Policy Holder:

Insurance Card (Front):

Upload File

(Max 15MB)

Insurance Card (Back):

Upload File

(Max 15MB)

Choose Time Slot for your COVID-19 Test:

Your scheduled testing date is: Friday, March 26th, 2021

We do our best to accomodate your first choice time slot. We will contact you if your first choice time slot is unavailable. If you do not hear from us, your first choice time slot was scheduled successfully.

First Choice Time Slot:

11:30am - 12:00pm

12:00pm - 12:30pm

12:30pm - 1:00pm

1:00pm - 1:30pm

1:30pm - 2:00pm

2:00pm - 2:30pm

Second Choice Time Slot:

11:30am - 12:00pm

12:00pm - 12:30pm

12:30pm - 1:00pm

1:00pm - 1:30pm

1:30pm - 2:00pm

2:00pm - 2:30pm

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 understand that email communications from Phosphorus, including my (my child’s) test results, may not be encrypted and/or secure. Should I wish to receive the results through a different method, I understand I may contact Phosphorus by phone, email, or standard mail with my request.

I consent and have read Everpoint Health's Terms & Conditions

Thanks for submitting!

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