Covid-19 Testing Form Please complete this Covid-19 Testing form to schedule an appointment with us. Covid-19 Testing Form Fill the form below and we will get back soon to you for more updates. Full Name* First NameLast Name Date of Birth* -Month -DayYearDate Email* [email protected] Gender* Please Select Male Female Not willing to Disclose Phone Number* Back Next Address* Street Address Street Address Line 2 CityState / Province Postal / Zip Code Please select one of the following COVID-19 tests: Please Select Covid-19 PCR Test - Results in 60 mins Covid-19 Antigen Test - Results in 30 minutes Covid-19 Antigen + FLU + A&B Test - Results in 15 minutes Are you feeling sick today? YesNo Do you currently have any of the following symptoms? (Select all that apply) Fever of at least 100.4 or feeling feverish/chills/repeated shaking with chills.New or worsening cough/sore throat/shortness of breath or difficulty breathingMuscle pain and fatigue/headache.New loss of taste or smell/nausea/vomiting or diarrheaNone of the above In the last 14 days, have you had contact (been within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period, starting from 2 days before illness onset until the time the infected person is isolated) with someone who's been diagnosed with (or is presumed to have) COVID-19? YesNo In the last 2 weeks, have you had any of the following exposures (select all that apply): Please Select International Travel Live in or have visited area where there has been community spread of COVID-19 None of the above Do any of the following describe your work setting (select all that apply)? Please Select Healthcare facility: I work in a clinic， hospital， nursing home， senior care facility， other healthcare facility First responder: I am a first responder， such as an ambulance worker， law enforcement officer， or firefighter. None of the above Do you have any of the following conditions (select all that apply)? Please Select Chronic lung disease or moderate to severe asthma Serious heart condition Neurologic condition that affects your ability to cough (e.g. had a stroke) Conditions that can cause a person to be immunocompromised (cancer treatment， smoking， bone marrow or organ transplant， etc.) Overweight/obese (body mass index of 40+) Diabetes Liver disease Chronic kidney disease or undergoing dialysis Pregnant None of the above Back Next Upload Government Issued ID (e.g. Driver's License) Browse FilesDrag and drop files here Choose a file Cancelof Upload the Front of the Insurance Card Browse FilesDrag and drop files here Choose a file Cancelof Upload the BACK of the Insurance Card Browse FilesDrag and drop files here Choose a file Cancelof Appointment for Covid-19 Testing Please select Yes, send me text messages for this appointment. Submit Should be Empty:
