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COVID-19 Intake Form
We are required to gather this information for potential CDC reporting.
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Name
*
Your answer
Email
*
Your answer
DOB
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
County
*
Your answer
Last 4 digits of Social Security Number
*
Your answer
Have you traveled out of the country in the last 2 weeks?
*
Yes
No
Have you been exposed to anyone that has tested positive?
*
Yes
No
Not that I'm aware of.
Do you have symptoms? If so, what are they and how long have they been occurring?
*
Your answer
Have you had prior COVID symptoms such as fever, cough, or respiratory illness in the past 3 months where testing for COVID-19 was not available?
*
Yes
No
Have you had exposure to others with COVID symptoms such as fever, cough, or respiratory illness in the past 3 months where testing for COVID-19 was not available?
*
Yes
No
Have you had public social interactions in the past 3 months where social distancing was violated or not possible or where masks were not being worn?
*
Yes
No
Do you have insurance? Please note that if you have insurance, you MUST select Yes and provide your insurance information.
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