Patient Information

First Name
Last Name
Middle Name
Date of birth
Male or Female
Has your child had Covid?	Yes No If yes, date of illness: Full Recovery? Yes No How were your symptoms? Mild - Less than 4 days or less of fever greater then 100.4, Less than one week of chills or lethargy Moderate - 4 days or more of fever greater than 100.4, 1 week or more of chills or lethargy, or a non ICU hospital stay Severe - ICU stay Any Cardiovascular symptoms? (Ex: Light headedness, dizziness, shortness of breath, chest pains, etc.)

Guarantor (Parent Information)

First Name
Last Name
Relationship to Patient
Best number to reach you
Email Address
Delivery Preference	Pick Up Email Fax
Which form are you requesting?
If faxing, please provide fax number
Who is receiving the fax?
As parent/guardian I give permission to release the requested information. (Clicking this box is your electronic signature)
Any Comments?