This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9]|800|811)$?)\s*(?:[.-]\s*)?([2-9]1[02-9]|[2-9][02-9]1|[2-9][02-9]{2})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/^(\d|[01]\d|(2[0-3]))(:[0-5]\d){2}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

Qs3hfwUpEZLRzEuuDCHT43DA6rNa7kv949qQpGzzmDsqqSNuZ7Ce94DrXIMJt4fhmnBWdz7eav5isUIF7eN4IKviqFHAFqDqPZoeXARkuiLBS7SQCiRZiGhiT7rXVZ

COVID Mobile Testing Registration Form

Provider Code:

You may be using a registration link for a testing site that is no longer in operation. Check to make sure the testing site you are planning to go to is still open before filling out the form by clicking on this link:

Utah Department of health Testing sites

Some testing sites have closed or been moved. To make sure you are going to the correct site, visit the following link:

Utah Department of Health Testing Sites.

Please complete this form for the individual being tested prior to the date scheduled for the on-site visit. The healthcare information contained in this form is collected for public health purposes only and will not be shared without your consent.

Por favor, complete este formulario para la persona que está siendo examinada antes de la fecha programada para la visita en persona. La información de salud contenida en este formulario se recoge sólo con fines de salud pública y no será compartida sin su consentimiento.

These testing locations are not available for people who need testing to attend events or to comply with repeat testing required by your employer.

Please visit https://coronavirus.utah.gov/utah-covid-19-testing-locations/ if you need testing for these purposes and search for non-state sponsored testing sites.

First Name
Primer nombre

* must provide value

Middle Name
Segundo nombre

Last Name
Apellido

* must provide value

Date of Birth
Fecha de nacimiento

* must provide value

M-D-Y

patient age

View equation

Date of birth is in the future, please enter a valid date of birth

Children under the age of 3 may only be tested using the Saliva PCR option at this site. If you desire a test using a different option, please refer to your pediatrician for guidance on Covid-19 testing for children.

Sex
Sexo

* must provide value

Female (Mujer)

Male (Hombre)

Other(Otro)

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Please fill out the parent/guardian information

Guardian First Name

Guardian Last Name

Guardian DOB

M-D-Y

Guardian Phone

Ethnicity
Etnicidad

* must provide value

Hispanic or Latino (Hispano o latino)

NOT Hispanic or Latino (NO Hispano o Latino)

Unknown (Desconocido)

Not Reported (No Reportado)

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Race
Raza

* must provide value

Asian (Asiático)

Black or African American (Negro o afroamericano)

Native Hawaiian or Other Pacific Islander (Nativo de Hawái u otra isla del Pacífico)

American Indian or Alaska Native (Indio americano o nativo de Alaska)

White (Blanco)

Other Race (Otra raza)

Unknown / Not Reported (Desconocida / No informado)

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Street Address
Dirección

* must provide value

City
Ciudad

* must provide value

State
Estado

* must provide value

Zip Code
Código postal

* must provide value

Phone number
Numero de teléfono

* must provide value

Please provide the email where you would like test results sent. The email provided will be used to send a secure email containing results from the test.

Por favor, proporcione el email donde quiere que se le envíen los resultados de la prueba. El email proporcionado será usado para enviar un email seguro con los resultados de la prueba.

* must provide value

Confirm Email Address:
Confirme la dirección de e-mail:

* must provide value

cemail

View equation

Email addresses do not match, in order to receive your test result over email you must confirm your email address.

If you would like to receive your test result over email, please confirm your email address.

Email Language Preference:
Preferencia de idioma de correo electrónico:

Individual Type

Patient/Resident

Healthcare Worker

Staff Member

Visitor

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Exposure risk category - Healthcare Worker/Staff

Use the picture below to help determine risk. Please ask your facility administrator to help you determine your risk level if uncertain.

Exposure risk category

Use the picture below to help determine risk. Please ask your facility administrator to help you determine your risk level if uncertain.

Exposure Risk

Low

Higher

No known risk

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Are you pregnant?

Yes (Si)

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Have you been in close contact with someone who tested positive for COVID-19 in the last two weeks?

-Close contact means you were closer than 6 feed or 1 meters (about 2 arms lengths) to the person who tested positive for a total of 15 minutes or longer while he or she was infectious. A person is infectious up to 2 days before they develop symptoms or test positive.

¿Ha estado en contacto cercano con alguien que haya salido positivo de COVID-19 en las últimas dos semanas?

-Cerrar el contacto significa que estuvo más cerca de 6 pies o 2 metros (a unos dos brazos de distancia) de la persona que salió positiva por un total de 15 minutos o más mientras estaba infectado. Una persona es infecciosa hasta 2 días antes de desarrollar síntomas o salir positiva.

Yes (Si)

Unknown (Desconocido)

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Do you have any of the following symptoms?
Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea

¿Tiene alguno de los siguientes síntomas?

Fiebre o escalofríos, Tos, Falta de aliento o dificultad para respirar, Fatiga, Dolores musculares o corporales, Dolor de cabeza, Nueva pérdida de gusto u olor, Dolor de garganta, Congestión o secreción nasal, Náuseas o vómitos, diarrea.

* must provide value

Yes (Si)

Unknown (Desconocido)

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Do you have any of the following symptoms? Check all that apply

* must provide value

Fever or chills

cough

shortness of breath or difficulty breathing

fatigue

muscle or body aches

headache

new loss of taste or smell

sore throat

congestion or runny nose

nausea or vomiting, diarrhea

What kind of Covid-19 test would you like?

(You may change your selection or choose once you arrive at the testing location.)

PCR Swab

PCR Saliva (May not consume food, beverages, or chew gum 30 minutes prior to test)

Unknown

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Have you received the Covid-19 vaccine?

Yes

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Has it been at least two weeks since your final dose?

Yes

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Do you have health insurance?

You will NOT be charged for a test, asked for proof of insurance, or billed insurance. Your response will not affect your ability to get tested at this site.

¿Tiene seguro médico?

No se le cobrará por una prueba, ni se le pedirá una prueba de seguro, ni se le facturará el seguro. Su respuesta no afectará la posibilidad de hacerse la prueba en este sitio.

* must provide value

Yes (Si)

I don't know (No sé)

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How did you hear about this testing site?

¿Cómo se enteró de este centro de pruebas?

News or social media (Noticias o medios sociales)

Community Health Worker (Trabajador de salud de la comunidad)

Religious organization (Organización religiosa)

Community organization (Organización comunitaria)

Local health department (Departamento de salud local)

Website or hotline (Sitio web o línea telefónica de ayuda)

Friends or family (Amigos o familiares)

School (Escuela)

Signs (Carteles)

Other (Otro)

If other, please explain:

Otro, por favor explique:

Why did you choose this testing site?

¿Por qué ha elegido este centro de pruebas?

Free (Gratis)

Doesn't require insurance (No requiere seguro médico)

Close to my home or easy to get to (Está cerca de mi casa o es de fácil acceder)

Doesn't require an appointment (No requiere una cita)

Offers the type of test I need (Ofrece el tipo de prueba que necesito)

I have come here before (He venido aquí antes)

Hours work with my schedule (Los horarios se adaptan a mi horario)

Friendly staff (Personal amable)

Other (Otro)

If other, please explain:

Otro, por favor explique:

I consent to receive my COVID-19 test result through a secure email. If I do not consent, I can receive a paper result at the testing location.
Doy mi consentimiento para recibir el resultado de mi prueba de COVID-19 a través de un correo electrónico seguro. Si no doy mi consentimiento, puedo recibir el resultado en papel en el lugar de la prueba.

* must provide value

I Consent (Doy mi consentimiento)

I DO NOT Consent (NO doy CONSIENTO)

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Please read carefully:

I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 as ordered by an authorized medical provider or public health official. I understand, as required by law, my test results will be disclosed to the county, state, or to other governmental entity. I consent to have the test result shared with a designated team representative. I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care, and treatment from my medical provider if I have questions or concerns, or if my condition worsens. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. I, the undersigned, have been informed about the test purpose, procedures, possible benefits, and risks. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time and have been given instructions how to obtain a copy of this Informed Consent. I voluntarily agree to this testing for COVID-19.

Por favor, lea con atención:

Autorizo a esta unidad de pruebas de COVID-19 a llevar a cabo la recolección y prueba de COVID-19 según lo ordenado por un proveedor médico autorizado o un oficial de salud pública. Entiendo que, como lo requiere la ley, los resultados de mis pruebas serán revelados al condado, estado o a otra entidad gubernamental. Consiento en que el resultado de la prueba se comparta con un representante designado del equipo. Entiendo que la unidad de pruebas no actúa como mi proveedor médico, esta prueba no reemplaza el tratamiento de mi proveedor médico, y asumo la completa y total responsabilidad de tomar las medidas apropiadas con respecto a los resultados de mi prueba. Estoy de acuerdo en que buscaré consejo, cuidado y tratamiento médico de mi proveedor médico si tengo preguntas o preocupaciones, o si mi condición empeora. Entiendo que, como con cualquier prueba médica, existe la posibilidad de un resultado falso positivo o falso negativo de la prueba de COVID-19. Yo, el abajo firmante, he sido informado sobre el propósito de la prueba, los procedimientos, los posibles beneficios y riesgos. Se me ha dado la oportunidad de hacer preguntas antes de firmar, y se me ha dicho que puedo hacer preguntas adicionales en cualquier momento y se me han dado instrucciones para obtener una copia de este Consentimiento Informado. Acepto voluntariamente esta prueba para COVID-19.

* must provide value

I consent (for myself) (Doy mi consentimiento (por mí))

I consent for my minor child (Doy mi consentimiento por mi hijo menor de edad)

I don't consent (No doy mi consentimiento)

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

COVID Mobile Testing Registration Form

You may be using a registration link for a testing site that is no longer in operation. Check to make sure the testing site you are planning to go to is still open before filling out the form by clicking on this link: Utah Department of health Testing sites

You have selected an option that triggers this survey to end right now.

You may be using a registration link for a testing site that is no longer in operation. Check to make sure the testing site you are planning to go to is still open before filling out the form by clicking on this link:

Utah Department of health Testing sites