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COVID-19 TESTING CONSENT
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Patient's Full Name:
*
First
Last
Patient Date of Birth:
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YYYY
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Student ID# (if available):
Parent/Guardian Name (if under 18 years old):
First
Last
Mobile Phone:
*
Email Address:
*
School District:
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Orange Public Schools
Newark Public Schools
Community Charter School of Paterson
Please Specify Newark School:
*
Please Choose
Abington Avenue
American History
Arts
Avon Avenue
Bard Early College
Barringer
Belmont Runyon
Benjamin Franklin
Bruce Street
Camden Street
Central
Chancellor Avenue
Cleveland Avenue
Dr. E. Alma Flagg
Dr. William H. Horton
Eagle Academy
ECC Central
ECC North
ECC South
Elliott Street
First Avenue
Fourteenth Avenue
George Washington Carver
Harriet Tubman
Hawthorne Avenue
Ivy Hill
John F. Kennedy
Lincoln
Louise A. Spencer
Luis Muñoz Marin
Malcolm X Shabazz
McKinley
Michelle Obama Elementary School
Mount Vernon
Newark School of Data Science and Information Technology
Newark School of Fashion and Design
Newark School of Global Studies
Newark Vocational
NJ Regional Day
Park Elementary
Peshine Avenue
Quitman Street
Rafael Hernandez
Ridge Street
Roberto Clemente
Salomé Ureña
Science Park
Sir Isaac Newton
South Seventeenth Street
Speedway Avenue
Sussex Avenue
Technology
Thirteenth Avenue
University
Weequahic
West Side
Please Specify Orange School:
*
Please Choose
Central Elementary School
Cleveland Street School
District Admin Building
Forest Street Community School
Heywood Avenue School
John Robert Lewis Early Childhood Center
Lincoln Avenue School
Oakwood Avenue Community School
Orange Early Childhood Center
Orange High School
Orange Preparatory Academy
Park Avenue School
Rosa Parks Community School
Scholars Academy
STEM Innovation Academy of the Oranges
The Twilight Program
Grade
*
Please Choose
Staff / Personnel
Other
K
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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.
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