Facility Intake Form

Overview

Organization/Facility Name

Organization Type

Address

City

State

Zip Code

Contact Person Name

Contact Phone

Contact Email

Medical Director Name (if applicable)

Secure Fax Number

Facility/Organization is interested in Covid-19 Testing

Number of Clients/Residents (congregate living) to be tested

Number of Employee/Volunteers/Vendors to be tested

For COVID-19 Testing:

We need staff support to collect specimens

We will collect our own specimens

Does your facility currently use Essentia Health for lab services?

Yes

Type of Test being Requested

Facility/Organization is interested in Covid-19 Vaccination

Date Request
1st Choice

Date Request
2nd Choice

Notes/Comments

Does your organization need COVID-19 testing support?

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