Coronavirus (COVID-19) Test Request Form

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Coronavirus (COVID-19) Test Request Form - Inglewood

Please make sure the Email address and Date of Birth are filled in correctly.

Email Address *

Please double check your email in order for you to receive the report on time.

ID number (Driver's License or Passport Number): *

First Name *

Last Name *

Date of Birth (MM/DD/YYYY) *

YYYY

Gender *

Male

Female

Others

Unknown

Race *

Caucasian

Asian

African American

American Indian or Alaska Native

Hawaiian or Pacific Islander

Others

Unknown

Ethnicity *

Hispanic

Non Hispanic

Unknown

Street Address *

Non-required: Street Address 2 (Such as #apt number)

City *

Los Angeles

Inglewood

Hawthorne

Other:

Zip Code *

Are you experiencing any of the following? (Check all that apply) *

Please select "Possible contact with positive patient" if you are not experiencing any symptoms

Fever or chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

Contact with and (suspected) exposure to COVID-19

Participated in high risk activities such as traveling

I received a positive Covid test result and need to repeat the test

None of the above

Required

Sample Collection date *

YYYY

Test Services *

Only PCR Nucleic Acid Test

Do you have insurance? *

Yes

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