Manual Health Worker Registration Form
Please use this form to register a customer when, or if internet service or App is not available. If you are completing this form, please make sure you have emailed support@safehealth.me to alert that the internet service or application is not available to register customers. Thank you!
Health Worker Registration Form
Test Site Name_________________________________________________________________________________________
Test Site Address_______________________________________________________________________________________
Insurance Provider_____________________________________________________________________________________
Insurance ID____________________________________________________________________________________________
Group Number_________________________________________________________________________________________
Plan Name______________________________________________________________________________________________
Coverage Date__________________________________________________________________________________________
Insurance Phone number______________________________________________________________________________
First Name______________________________________ Last Name___________________________________________
Email Address__________________________________@______________________________________________________
Phone Number_________________________________________________________________________________________
Date of Birth___________________________________________________________________________________________
Race____________________________________________________________________________________________________
Ethnicity________________________________________________________________________________________________
Address________________________________________________City________________________St________Zip________
(What about Terms and Conditions, Privacy Policy, HIPAA Consent, Terms of Service?)
Are you experiencing new or worsening onset of any of the following (Please check all that apply):
o Fever
o Cough
o Loss of Smell or Taste
o None
2. What is your temperature?
3. How many days have you experienced these symptoms?
4. Are you experiencing new or worsening onset of any of the following (Please check all that apply):
o Chills
o Muscle pain
o Sore throat
o Loss of smell or taste
o Vomiting
o Diarrhea
o None
5. Have you had prolonged, close contact (15 minutes or longer at less than 6 feet) with someone diagnosed positive for COVID-19?
o Yes
o No
6. Is this person symptomatic?
o Yes
o No
7. Cleared for work?
o Yes
o No
□ Check this box to confirm that this data has been updated into the system Completed by__________________________________________________ Date____________________________