CALL US: (603) 536-1120

COVID-19 Test Request Form

This form is to request an appointment and provide consent for COVID-19 testing at Speare Memorial Hospital. Your information will be kept confidential and only used for scheduling, diagnostic, tracking, and billing purposes. By completing this form you are voluntarily sharing this information. Information on this form may be shared with the New Hampshire Division of Public Health Services for public health purposes.

  • Patient Information
  • Date Format: MM slash DD slash YYYY
  • Please enter only the carrier name, There is a 25 character limit.
  • Guarantor for under 18:
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • COVID-19 TESTING CONSENT: By completing this form and requesting an appointment I authorize Speare Memorial Hospital to administer and process a nasopharyngeal, anterior, or oropharyngeal swab for a COVID-19 Test. I further understand, agree, certify, and authorize the following:

    1. I am the parent or legal guardian (if the patient is a minor or dependent) of the patient requesting testing.

    2. I understand that this testing is voluntary and that I have the right to refuse this test.

    3. I understand that the sample I provide might produce a false positive or negative.

    4. I understand that I have a right to view my test result and a right to discuss my results and any treatment, precautions, and quarantine if so necessary, required for my health and safety and the safety of my family and the community, with my healthcare provider.

    5. I understand that a positive test result is required by RSA 141-C:7 and RSA 141-C:8 to be shared with the New Hampshire Department of Health and Human Services, Division of Public Health.

    6. I authorize the test results to be shared with Speare Memorial Hospital, the New Hampshire Department of Health and Human Services, Department of Public Health Services, and the healthcare provider ordering the COVID-19 test.

  • (school or employer).
  • 8. I understand that the results of my test will remain confidential as allowed under state and federal law.

    9. I authorize Speare Memorial to bill the insurance that I have provided on this request form for the COVID-19 test requested.

    10. I understand that this consent will remain in effect for one (1) year from the date of this request unless specifically revoked in writing by the Undersigned before the end of one (1) year.

    11. I have read, agree to, and understand this Consent Form. I authorize disclosure of my medical information as described above. Further, I agree to hold harmless Speare Memorial Hospital and any other entity administering this test, including its employees, agents and contractors from any and all liability claims.

  • (parent signature if under 18).
  • Date Format: MM slash DD slash YYYY
Translate »
Scroll to Top