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:
arrow&v
Insurance Information:
Do you have insurance?
arrow&v
Upload File
Upload File
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:
Second Choice Time Slot:
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.

Thanks for submitting!