Covid-19 Testing Form
Fill the form below and we will get back soon to you for more updates.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Gender
*
Please Select
Male
Female
Not willing to Disclose
Phone Number
*
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please select one of the following COVID-19 tests:
Please Select
Covid-19 PCR Test - Results in 60 mins
Covid-19 Antigen Test - Results in 30 minutes
Covid-19 Antigen + FLU + A&B Test - Results in 15 minutes
Are you feeling sick today?
Yes
No
Do you currently have any of the following symptoms? (Select all that apply)
Fever of at least 100.4 or feeling feverish/chills/repeated shaking with chills.
New or worsening cough/sore throat/shortness of breath or difficulty breathing
Muscle pain and fatigue/headache.
New loss of taste or smell/nausea/vomiting or diarrhea
None of the above
In the last 14 days, have you had contact (been within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period, starting from 2 days before illness onset until the time the infected person is isolated) with someone who's been diagnosed with (or is presumed to have) COVID-19?
Yes
No
In the last 2 weeks, have you had any of the following exposures (select all that apply):
Please Select
International Travel
Live in or have visited area where there has been community spread of COVID-19
None of the above
Do any of the following describe your work setting (select all that apply)?
Please Select
Healthcare facility: I work in a clinic, hospital, nursing home, senior care facility, other healthcare facility
First responder: I am a first responder, such as an ambulance worker, law enforcement officer, or firefighter.
None of the above
Do you have any of the following conditions (select all that apply)?
Please Select
Chronic lung disease or moderate to severe asthma
Serious heart condition
Neurologic condition that affects your ability to cough (e.g. had a stroke)
Conditions that can cause a person to be immunocompromised (cancer treatment, smoking, bone marrow or organ transplant, etc.)
Overweight/obese (body mass index of 40+)
Diabetes
Liver disease
Chronic kidney disease or undergoing dialysis
Pregnant
None of the above
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Upload Government Issued ID (e.g. Driver's License)
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Upload the Front of the Insurance Card
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Upload the BACK of the Insurance Card
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Appointment for Covid-19 Testing
Please select
Yes, send me text messages for this appointment.
Submit
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