Visit Information

Expected COVID Test Date and Approximate Time *

Reason for Test (sore throat, cough, shortness of breath, fever)

Date of Positive COVID Exposure *

Family Physician Name

Patient Information

First Name *

Middle Initial

Last Name *

Date of Birth: (DD/MM/YYYY) *

Sex *

Race *

Ethnicity *

Primary Language *

Address 1 *

Address 2

City *

State *

Zip Code *

Phone Number: (i.e., 555-555-5555) *

Phone Number Type

Home
Cell

Email Address (For signing up and receiving results through our portal.)

Is the Patient currently employed?

Yes
No

(If yes) Employer Name and Address

(If yes) Employer Phone: (i.e., 555-555-5555)

Next of Kin Information

First Name

Middle Initial

Last Name

Address 1

Address 2

City

State

Phone Number (i.e., 555-555-5555)

Email Address

Work Number (i.e., 555-555-5555)

Relation to Patient

Emergency Contact

First Name

Middle Initial

Last Name

Address 1

Address 2

City

State

Phone Number (i.e., 555-555-5555)

Work Number (i.e., 555-555-5555)

Relation to Patient

Insurance Information

Do you currently have insurance?

Yes
No

Insurance Company Name

Policy Number

Group Number

Policy Holder Name

Policy Holder Date of Birth: (DD/MM/YYYY)

Policy Holder Marital Status

Responsible Party Information

Is the Responsible Party the same as the patient?

Yes
No

Is there another Responsible Party?

Yes
No

Additional Comments

Before arrival at the Missouri State Fairgrounds, please call 660-827-7900 to let us know you are on your way. Please email us a copy of your insurance card (front and back) and photo ID (if not already on file) to bwc@brhc.org.