PCR COVID TEST INTAKE
PRIVACY STATEMENT: The information collected on this form is for the use of COVID SARS-19 Testing and obtained by the City of Hartford HHS Department. Information obtained in this form can/will only be shared under the provision of the signed consent. HHS will adhere to all confidentiality guidance. * Indicates required question
Street Address Line 2
State / Province
Postal / Zip Code
Native Hawaiian or Pacific Islander
Indigenous/American Indian/Alaskan Native
Please upload a copy of your insurance card front and back
Drag and drop files here
Choose a file
Do you have a primary medical doctor (PCP) that you have seen in the last 2 years?
Yes, but I have not seen the provider in 3 or more years
In the last 7 days have you experienced any of these symptoms? Please check the symptoms that apply
Nasal congestion or Runny Nose
Shortness of Breath
None of the Above
In the last 7 days have you traveled outside of the US?
Are you seeking this test for personal or professional reasons?
Personal (travel, exposure, confirmatory test etc..)
Professional (employment, educational, required by someone else)
Are you pregnant?
Have you had a COVID-19 Vaccination
When did you receive your last COVID-19 vaccination?
Do you plan to wait for your results (up to 30 min*) or prefer a phone call? If phone call is it ok to leave a message?
I plan to wait on site for my results
I prefer a call and it is ok to leave a message if I do not answer
I prefer a call. DO NOT LEAVE A MESSAGE
Please, give your location
Parking Spot #1
Parking Spot #2
Should be Empty: