Testing Appointment Form

Testing Appointment Form

COVID-19 Initial Survey
Are you currently experiencing any symptoms?

High fever Cough Difficulty in breathing Persistent pain or pressure in the chest Body aches Nasal congestion Runny nose Sore throat Diarrhea None
Please select your age group

0 - 10 11 - 19 20 - 44 45 - 64 65 - 74 75 - 90 90+
Which of these areas is the closest to you?

Silsbee 1 Beaumont 2 Houston 3 Dallas 4
Get Your Appointment
Get Your Appointment
Get Your Appointment
Please check all that apply

Anemia Asthma Arthritis Cancer Gout Diabetes Epilepsy Seizures Heart Disease Heart Attack Rheumatic Fever High Blood Pressure Digestive Problems Ulcerative Colitis Hepatitis Kidney Disease Liver Disease Thyroid Problems Tuberculosis Venereal Disease Neurological Disorders Bleeding Dİsorders Lung Disease (Chronic Obstructive Pulmonary Disease)
Name

First Name Last Name
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
By submitting I hereby confirm that the information I have given above is true, and that I will comply with the terms and conditions outlined above.
Signature

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