Covid-19 Questionnaire
Phone: (956) 372-1405
Location: 1080 E LOS EBANOS BLVD BROWNSVILLE,TEXAS 78520
**PLEASE REMEMBER TO BRING YOUR ID AT THE TIME OF TESTING**
Full Name / Nombre Completo *
Date of Birth / Fecha de Nacimiento *
MM
/
DD
/
YYYY
Sex / Sexo *
Phone number // Número de teléfono *
Format/Formato (956) 372-1405
E-mail/ Correo Electronico *
Home Address/ Direccion de Casa *
City/ Ciudad *
State/ Estado *
Zip Code/ Codigo Postal *
Are you over 18? / Eres mayor de 18 años? *
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