TELEHEALTH COVID-19 ASSESSMENT REGISTRATION

Please complete the form below to register online for your Telehealth Covid-19 Assessment through UMC.

PATIENT INFORMATION
Last Name: * First Name: *
Phone #: * Date of Birth: * MM/DD/YYYY
Employee ID#: Employer Name:
 
INFORMED CONSENT

Please read the "Informed Consent for COVID-19 Diagnostic Testing" document. Clicking this link will open the document in a separate browser tab.

Acknowledgment

AUTHORIZATION AND CONSENT FOR TELEHEALTH SERVICES

Please read the "Authorization and Consent for Telehealth Services" document. Clicking this link will open the document in a separate browser tab.

Acknowledgment

RECEIVE RESULTS VIA TEXT-MESSAGING

REQUEST TO RECEIVE RESULTS VIA TEXT-MESSAGING

To facilitate your timely receipt of testing results, UMC offers patients the ability to receive their testing results via unencrypted methods of electronic communication, such as text messaging. Due to the nature of unencrypted electronic messages, transmitted information may be vulnerable to be read by unauthorized third parties, inadvertently addressed to the wrong party, or improperly accessed during transmission or storage. With full knowledge and understanding of these risks, I request that UMC, or any UMC employee, agent, affiliate, or contractor, provides me with my COVID-19 testing results via the following means of unsecured electronic communication:

Text-Messaging: (cell phone number)

Should the above-identified contact information change or no longer be utilized by me, I shall promptly inform UMC

For assistance with UMConnect or the MyChart app, please call 702-789-5160.

To speak with a UMC representative, please call 702-383-2619.

To submit this form and continue the scheduling process, please click the "Schedule your Telehealth COVID-19 Assessment"
button below.