Admission Form Covid Testing

COVID-19 TESTING REGISTRATION

To expedite the registration process, please enter your name and date of birth exactly as they appear on your ID.

You must be 18 or older to register.

As a helpful reference for reading your test results:
Not Detected = Negative
Detected = Positive
UMC will contact you directly if your result is positive.

PATIENT INFORMATION
Last Name:	*	First Name:	*
Phone #:	*	Date of Birth:	* MM/DD/YYYY
Employee ID#:	*	Employer Name:

INFORMED CONSENT AND AUTHORIZATION

Please read the "Informed Consent for COVID-19 Diagnostic Testing" document. Clicking this link will open the document in a separate browser tab.

Acknowledgment

I acknowledge and agree that I have read, understand, and agreed to the statements contained within this document.

Please read the "Authorization for Disclosure of COVID-19 Test Results to Employer" document. Clicking this link will open the document in a separate browser tab.

Authorization

I acknowledge and agree that I have read, understand, and agreed to the statements contained within this document.

To speak with a UMC representative, please call 702-383-1800. Our team is happy to offer scheduling assistance and support for UMConnect and the MyChart app.