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Phone: 205-349-1040 | Fax: 205-349-4015

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Covid-19 Test

Patient Registration Form

Patient Information

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Age

Check here if you are a current patient with Taylorville Family Medicine

Race

Cell Phone

Alternative Phone

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Residence Address

County

Insurance

***We only accept Medicare and BCBS for non-established patients

Please have your Driver's License and Insurance Card ready to copy

Clinical Information

Reason for Testing

Choose an option

Symptoms Questionnaire - please select all tht apply

None

Cough

Fever

Chills

Shortness of Breath

Chest Pain

Diarrhea

Nausea

Vomiting

Body aches

Joint pain

Headache

Fatigue

Runny nose

Nasal congestion

Sore throat

Loss of Sense of taste and smell

Other

Date of Symptoms onset (MMDD)

Previous Covid-19 diagnosis?

Have you been diagnosed with any of the following underlying conditions?

Body Mass Index (BMI) ≥30 kg/m2 or obesity

Cardiovascular Disease

Diabetes Mellitus

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Taylorville Family Medicine
WINCHESTER SQUARE
7700 Hwy 69 S, Tuscaloosa, AL 35405

Sick Clinic at Bear Creek
TAYLORVILLE CORNERS
601 Bear Creek Rd. Tuscaloosa, AL 35405

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7:15 AM - 7:00 PM

7:15 AM - 5:00 PM

8:00 AM - 6:00 PM

8:00 AM - 5:00 PM