COVID-19 Screening & Consent Form (Mobile Visit)

Patient Full Name

DOB

Month

Day

Year

Date of Appointment

Location

Screening Questions (check Yes/No)

1. In the last 10 days, have you had fever/chills?

Yes

No

2. In the last 10 days, have you had cough, shortness of breath, or difficulty breathing?

Yes

No

3. In the last 10 days, have you had sore throat, congestion/runny nose?

Yes

No

4. In the last 10 days, have you had new loss of taste or smell?

Yes

No

5. In the last 10 days, have you had nausea/vomiting/diarrhea not otherwise explained?

Yes

No

6. In the last 10 days, have you tested positive for COVID-19?

Yes

No

7. In the last 10 days, have you had close contact with someone confirmed/suspected COVID-19?

Yes

No

8. In the last 10 days, have you been advised to isolate or quarantine?

Yes

No

If YES to any above, explain:

Consent & Acknowledgement

- I certify the answers above are true to the best of my knowledge.

- I understand Labpreps may reschedule or take additional precautions if screening indicates increased risk.

- I agree to notify Labpreps if I develop symptoms within 48 hours after my visit (if applicable).

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Printed Name:

Date

Month

Day

Year

Covid-19 Consent & Release

COVID-19 Screening & Consent Form (Mobile Visit)

© 2026 LabPreps, LLC. All rights reserved.

Phone

Email

Address

Hours Of Operations

Quick Links

About

FAQs

Services

Company Policies

Privacy and Terms

Contact Us