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Patient First Name

Patient Last Name

Visit Day

Visit Time

Cell Phone Number

Patient Age

Date of Birth

Address

Reason for Visit

Patient Type

Has your insurance changed since your last visit with Trinity Health IHA Medical Group?

Insurance Carrier

Insurance carrier (free text if not listed)

Has your insurance changed since your last visit to Trinity Health IHA Medical Group?

Insurance Policy #

Enter your insurance carrier

Do you have a Primary Care Physician?

Insurance Group #

What is your primary care physician's name?

Enter your address

Were you referred to be seen for your symptoms today by your Michigan Medicine care team?

Enter Insurance policy #

Would you like to be connected with a primary care physician?

I attest that I have been informed all test results, including COVID-19 testing, will be delivered in the MyChart Patient Portal, not over the phone.

Do you need a COVID test?

Do you have COVID symptoms?

Reason for COVID test:

Primary Care Physician Name

Do you want a COVID Test?