DSHS TESTING - ZEPHYR ISD

Zephyr Independent School District

K-12 COVID-19 Testing Program

Name of Person Being Tested*

First Name

Last Name

Date of Birth for Person Being Tested*

Testing Location*

Zephyr Independent School District

Is the individual a student or a faculty/staff member?*

Student Faculty/Staff

Staff or Student ID *

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.*

I agree

Parent or Guardian for the Student*

First Name

Last Name

Best Contact Phone Number for Parent/Guardian*

Best Contact Phone Number*

Do you consent to receiving test results via email?*

Yes. Please email my results. No. Please only call me with my results.

Email Address for Parent/Guardian*

Confirm Email Address for Parent/Guardian *

Email Address *

Confirm Email Address *

Informed Consent for K-12 COVID-19 Testing Program

I consent to being tested under the terms and conditions above:*

[clear]

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:*

First Name

Last Name

SARS Antigen Results*

Negative Positive Inconclusive Results; patient will need to be retested