COVID-19 Testing: Pre-Registration Form

*= Required

Language
This form must be filled out in English. If you require interpreter services to complete the registration questions included in this form, Tufts MC will have interpreter support available on-site at our testing site to walk you through the process. Please inform a member of our staff upon arrival.
Patient Identification

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.

This field is optional, however it is also the most absolute way to identify you and your assigned medical record at Tufts MC. If provided, Tufts MC will only use this information as a minimum necessary data element to verify your identity and will only reflect the last four digits of your SSN on printed registration materials. Once it is on file, you can ask an appropriate Tufts MC employee to look you/ your medical record number up by searching for your SSN. Your medical record number will remain uniquely assigned to you indefinitely, at our hospital.
Contact Info

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.

Note: If the patient is a Minor (< 18 years of age) the Phone Number provided must be a Legal Parent/ Guardian's Contact Information Optional if applies

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.

i.e. Other than a homeless shelter; including a nursing home, assisted living, board and care home (senior living), group home, foster care, residential care for people with intellectual and developmental disabilities, psychiatric treatment facility, or other similar congregate setting.
Tufts MC has a patient portal option you can use to view-print-save your COVID test results.
You must provide an active email account in order to benefit from this technology.
Note: If the patient is a Minor (< 18 years of age) the email address provided must be a Legal Parent/ Guardian's Contact Information.

Please visit our website at tuftsmedicalcenter.org/covidresults for additional information about the use of our patient portal for this specific purpose.
Vital Statistics
Marital Status is a Core Health Data Element defined by the National Committee on Vital Health Statistics. The Committee recognizes that a person's social support system can be an important determinant of his or her health status, access to health care services, and use of services. Marital status is one element that is sometimes used as a surrogate for the social support system available to an individual and can be important for program design, targeting of services, utilization and outcome studies, or other research and development purposes. It also may be required to verify benefits. https://aspe.hhs.gov/report/core-health-data-elements-report-national-committee-vital-and-health-statistics/core-health-data-elements
Race & Ethnicity

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.

Emergency Contact
Tufts MC will only utilize an Emergency Contact indicated in a patient's medical record if it is determined to be in the best interest of the patient in order to lessen a serious and imminent threat to their health or safety.
Guarantor Requirements

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.

Patient’s Guarantor [if applies]

If you answered “Yes” to the question above, please provide the Guarantor information requested in this section below.

Health Insurance Information
If you have active insurance, please enter your Member ID in this field.
Primary Policyholder
This field is optional, however it is also the most absolute way to verify the assigned Primary Policyholder's/ Subscriber's identity and your [the Patient's] insurance coverage. If provided, Tufts MC will only use this information as a minimum necessary data element.
Primary Care Physician
*If available/ applies, we will ask you for the First and Last Name of your Primary Care Provider and their practice location; including Out-of-State providers. Note: We will automatically fax your PCP a copy of your test results to support continuity of care. You will be notified of your test results in addition to your PCP.
COVID Testing History
"Of any kind" includes PCR and/ or Antibody testing
Does not include Antibody testing results
Travel History
Reason for Testing
Please select one of the options listed as it applies to your circumstance.
COVID Symptoms
Note that you must unselect ASYMPTOMATIC if you want to select other symptoms.
If you are unable to recall the exact date, please provide an estimated date
Employment
"Direct Patient Contact” refers to physical touch involved in the course of providing patient care
Including Wellforce and Tufts University employees
Indicate your job/ profession in the free text field as it applies. 'Unemployed' is also an accepted response.

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.