Patient's Full Name: *

First

Last

Patient Date of Birth: *//

Student ID# (if available):

Parent/Guardian Name (if under 18 years old):

First

Last

Mobile Phone: *

Email Address: *

School District: *

Orange Public Schools
Newark Public Schools
Community Charter School of Paterson

Please Specify Newark School: *

Please Specify Orange School: *

Grade *

By submitting this form, you are consenting for COVID-19 weekly testing until August 31, 2023. If you or the patient feels ill, you should seek medical attention as soon as possible. You consent that the information on this form is accurate and agree to receive results via email or text. I understand this test does not confirm a medical evaluation. You authorize JL Hudson Holdings LLC or its assignee to bill your insurance/health coverage for these services; when available. You authorize us to release any information/medical records for billing and reimbursement to state/county authorities as required by state guidelines. If your insurance company pays you directly for our services, you agree to endorse that payment to us within 15 days of receipt. You consent to allowing JL Hudson Holdings LLC to share your results with Orange Public Schools or Newark Public Schools.

Patient/Parent/Guardian Consent: *

I agree and consent to all terms. I agree to receive text messages and emails regarding the patient's COVID-19 test results.