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Please reflect your [the Patient's] legal name in the fields below. "Legal" refers to how your name and gender appear on a Government-issued form of identification i.e. Driver's License, Social Security Card, Passport, Green Card, etc.
A Tufts MC Nurse will call you by phone to relay your COVID test results within 24 to 72 hours from specimen collection.
You must provide a US Phone Number where you can be reached. If you do not have a US Phone Number, please provide the Phone Number of a person you are residing with locally/ will be in close contact with throughout your travels and can retrieve messages from.
By providing the Phone Number of another individual besides yourself, you are consenting to Tufts MCs use of that Phone Number to contact you. If you are not readily available when we call, we [Tufts MC] will only relay that we are trying to reach you [the Patient] and ask for you to
please call us back at a designated Phone Number as soon as possible. Tufts MC will never relay the purpose of our call or your test results on a voicemail or to anyone other than the Patient [you]. If your primary contact is an International Phone Number, please provide that contact
information as well, in the optional field provided below.
A US Address is REQUIRED for all patients completing this form. If your permanent residence is not the United States of America, please provide the local, US address where you are currently lodging.
All Hospitals and Laboratories are required to report information on race and ethnicity to the Department of Public Health. Race and Ethnicity is a critical element in public health surveillance efforts. Obtaining racial and ethnic data on cases of COVID-19 specifically, is crucial for
examining the population and locations most impacted by the illness and helps guide appropriate response to the pandemic.
If the patient is a Minor (< 18 years of age) or an Adult & Unable to Consent for Self, we require a Guarantor on record.
The Guarantor is the person responsible for ensuring payment of rendered services.
This person is not necessarily the same as the primary policyholder for the Patient's health insurance.
All Patients who are Minors (< 18 years of age) must be accompanied to our testing site by a Legal Parent/ Guardian in order to receive testing at our facility.
If you answered “Yes” to the question above, please provide the Guarantor information requested in this section below.
Important Reminder: Please bring a Government-issued, preferably photo form of identification with you to the testing site i.e. Driver's License, Passport, Green Card, etc., as well as, your insurance card if applies.