Midway Independent School District

K-12 COVID-19 Testing Program



Name of Person Being Tested | Nombre de la persona examinada*
Date of Birth for Person Being Tested | Fecha de nacimiento de la persona examinada*
Testing Location | Ubicación del examen*
Is the individual a student or a faculty/staff member? | ¿El individuo es un estudiante o miembro de la facultad/personal?*
You will need to have this number on site for testing check-in.
By clicking below, you are acknowledging that the person to be tested is a minor student, their parent or guardian must proceed with registration and consent signature. | Al hacer clic, reconoce que la persona a ser examinada es un estudiante menor de edad, y su padre o tutor debe proceder con la inscripción y la firma de consentimiento.*
Parent or Guardian for the Student | Padre o tutor del estudiante*
Do you consent to receiving test results via email? | ¿Acepta recibir los resultados por correo electrónico?*

Use your mouse or finger to draw your signature above
Informed Consent Signature Date/Time*
:  

Resulting

PATIENT TEST RESULTS


Results Entry Date/Time*
:  
Name of staff member REPORTING the results:*
SARS Antigen Results*
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