CDM Covid 19 PCR Testing and Rapid Antigen Test Appointment

COVID-19 PCR and Rapid Antigen Testing

Appointment and Consent Form
Type of Testing*
Choose a location*
Appointments- CDM #2*
Appointments CDM #1*
Appointments CDM #3*
Appointments CDM #4*
Name*

First NameLast Name
Birth Day*

MonthDayYear
Gender

FemaleMaleOther
Cell Phone Number*

Area CodePhone Number
Email
Please enter email if you wants to receive the results via email.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you symptomatic?*

YesNoUnknown
When did your symptoms begin?

MonthDayYear
Date