COVID-19 Testing Forms

Testing at Harris Hall

Prior to participating in arrival testing or wide-net or surveillance testing, please print, complete, and bring these required forms to Harris Hall with you. 

  • General Consent Form - be sure to also view the Notice of Privacy Practices
  • TriHealth Authorization Form - Instructions:
    • Top section (with the boxes). The ony sections you need to complete are: 
      • Patient Name
      • Last 4 digits of your Social Security Number, if you have one
      • Date of birth
      • Accurate phone number
      • Address (should be your local address)
    • 2. Initial next to each line you authorize
      • If you are a student athlete, you should authorize Athletics in addition to the other lines
    • 3a. Check the OTHER box for COVID TEST RESULTS
    • 3b. You do not need to check the Billing Records box
    • 3c. Check All dates or treatment (this will include all dates you get a COVID test from TriHealth)
      • Only COVID Test Results will be shared. The other conditions listed are not part of your COVID results record, therefore they will not be shared. 
    • 9. Enter "May 15, 2021" for the date of expiration on the first; you can leave the second part blank or write N/A. 
    • Sign and print your name, and include the current date at the bottom of the document. Relationship to patient: select "Other" and write in "Self" unless you are under the age of 18, in which case your parent or guardian should complete this form for you. 
  • Voicemail Results Form - allows your COVID-19 test results to be left on a voicemail or via email. Complete all fields of the form, including: patient name, date of birth, your cell phone number, your email address, your signature and the current date. 

You should also visit COV19.Health and register as a new patient. Use the Office Location Code: TRIMIAMI. 

You will be able to complete these steps at Harris Hall if need be, but it may increase your wait time. 

If you have already had COVID-19 and recovered, please upload medical documentation of the positive diagnosis to MedProctor.

Testing at Millett Hall (and Remain-in-Room Testing in the Residence Halls)

You need only complete three of the following four forms one time. The Gravity Diagnostics Patient Info Form must be completed each time you take a test for the Remain-in-Room plan. 

  • General Consent Form - be sure to also view the Notice of Privacy Practices
  • TriHealth Authorization Form - Instructions:
    • Top section (with the boxes). The ony sections you need to complete are: 
      • Patient Name
      • Last 4 digits of your Social Security Number, if you have one
      • Date of birth
      • Accurate phone number
      • Address (should be your local address)
    • 2. Initial next to each line you authorize
      • If you are a student athlete, you should authorize Athletics in addition to the other lines
    • 3a. Check the OTHER box for COVID TEST RESULTS
    • 3b. You do not need to check the Billing Records box
    • 3c. Check "All dates or treatment" (this will include all dates you get a COVID test from TriHealth)
      • Only COVID Test Results will be shared. The other conditions listed are not part of your COVID results record, therefore they will not be shared. 
    • 9. Enter "May 15, 2021" for the date of expiration on the first; you can leave the second part blank or write N/A. 
    • Sign and print your name, and include the current date at the bottom of the document. Relationship to patient: select "Other" and write in "Self" unless you are under the age of 18, in which case your parent or guardian should complete this form for you. 
  • Voicemail Results Form - allows your COVID-19 test results to be left on a voicemail or via email. Complete all fields of the form, including: patient name, date of birth, your cell phone number, your email address, your signature and the current date. 
  • Gravity Diagnostics Patient Info Form - You need only complete the "PATIENT INFO" section with your last name, first name, local address, city/state/zip, date of birth, and phone number, and sign the bottom of the form next to "patient signature." Please leave the rest of the form blank.

If you have already had COVID-19 and recovered, please upload medical documentation of the positive diagnosis to MedProctor