Patient Health Questions | CoastLine Medical

GUV Lighting
PPE Products
VA Hospitals
Store
About
Contact
More

Doctor Using Digital Tablet

Patient COVID-19 eRegistration

Please fill out the following eRegistration Form prior to your scheduled appointment time.

SPECIAL INSTRUCTIONS REGARDING MINORS:

Age 10-15: Parent or legal guardian needs to fill out form and accompany patient to visit.
Age 16-17: Parent or legal guardian needs to fill out form.

First Name

Last Name

Email Address

Phone

Gender

Date of Birth

Emergency Contact Name

Emergency Contact Phone

Have you experienced any of these symptoms? (select all that appply)

Chills

Headache

Congestion or Runny Nose

Muscle or Body Aches

Cough

Nausea or Vomiting

Diarrhea

New Loss of Taste or Smell

Fatigue

Shortness of Breath or Difficulty Breathing

Fever

Sore Throat

Exactly what date did these symptoms begin?

Do you have any of the following medical conditions? (select all that apply)

Asthma or Chronic Lung Disease

Extreme Obesity

Cirrhosis of the Liver

Hypertension or High Blood Pressure

Conditions that result in a weakened immune system, including cancer treatment

Kidney Failure or End Stage Renal Disease

Diabetes

Serious heart condition, such as congestive heart failure

Diseases or conditions that make it harder to cough

Are you currently pregnant? (Optional)

No

Yes

In the past 14 days, have you had known or suspected exposure to the SARS-CoV-2 virus or a COVID-19 patient?(e.g. been exposed to someone with COVID-19 or been in a large public gathering where exposure is suspected)

No

Yes

Are you a resident in a special setting where the risk of COVID-19 transmission may be high?(This may include long-term care, correctional and detention facilities; homeless shelters; assisted-living facilities and group homes.)

No

Yes

Is this your first time taking the COVID-19 test?

No

Yes

Do you work in health care?

No

Yes

Do you work in a special setting where the risk of COVID-19 transmission may be high? (This may include long-term care, correctional and detention facilities; homeless shelters; assisted-living facilities and group homes.)

No

Yes

Have you been prioritized for testing by a medical professional?

No

Yes

Have you previously tested positive for COVID-19?

No

Yes

See how swabbing is performed.

I acknowledge that I have answered these questions truthfully to the best of my knowledge. I understand that I must perform my own nasal swab or bring someone to do it for me.

I acknowledge that I have read and agreed to the following Privacy Policy and understand how my information will be used.View Privacy Policy

Initials

Today's Date

CONTACT

509 Viking Drive Suite E,

Virginia Beach, VA 23452

Tel: 757.275.8050

OPENING HOURS

Monday - Thursday: 9:00am – 5:00pm Friday: 9:00am – 3:00pm

Partners

Disc Disease Solutions

SUBSCRIBE TO JOIN OUR MAILING LIST

Thanks for submitting!

© 2021 by Coastline Medical Inc. Powered by TOCCreative.

COVID-19 TESTING

509 Viking Drive Suite E, Virginia Beach, VA 23452

Tel: 757.275.8050