Visit Information

 

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

 
 

Patient Information

 
 
 
 
 
 
 
 
 
 
 
 

Phone Number Type


 

Is the Patient currently employed?


 

(If yes) Employer Name and Address

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

 

Next of Kin Information

 

Emergency Contact

 

Insurance Information

Do you currently have insurance?


 

Responsible Party Information

Is the Responsible Party the same as the patient?


Is there another Responsible Party?


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.