Registration Form
( Pre-Registration Form )
Appointment Requested for !
Please Select
Vaccination
Covid Testing
General Doctor's Visit
Appointment
Name
First Name
Last Name
Gender
Female
Male
Email ( Optional )
example@example.com
Phone Number
Please enter a valid phone number.
Address ( Optional )
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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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
High fever
Difficulty in breathing
Body aches
Runny nose
Diarrhea
Cough
Persistant pain or pressure on chest
Nasal congestion
Sore throat
Other
Have you been diagnosed with COVID-19?
Yes
No
If yes, please provide further details (date of diagnition, were you hospitalized or not, treatment, etc.)
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