COVID-19 Testing Registration Form
( Pre-Registration Form )
Email ( Optional )
Please enter a valid phone number.
Address ( Optional )
Street Address Line 2
State / Province
Postal / Zip Code
Health and Medical History ( Optional )
Do you have any chronic health condition?
Please indicate all health issues that are considered within the risk group
Please check the symptoms that apply
Loss of taste or smell
Difficulty in breathing
Persistant pain or pressure on chest
Have you been diagnosed with COVID-19?
If yes, please provide further details (date of diagnition, were you hospitalized or not, treatment, etc.)
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform