Kirk's Pharmacy COVID-19 Screening and Testing Form
* Required
Patient Full Name
*
Your answer
Date of Birth (TEST RECIPIENT MUST BE 16 YEARS OR OLDER)
*
MM
/
DD
/
YYYY
Sex
*
Male
Female
Other:
Required
Address
*
Your answer
Zip Code
*
Your answer
Email
*
Your answer
Phone
*
Your answer
Primary Care Provider and Contact
*
***If you do not have a PCP, just mark N/A - this will not impact your ability to recieve a test kit***
Your answer
Race (Check all that Apply)
*
American Indian or Alaska Native
Black/African American
Native Hawaiian or Pacific Islander
Asian
White
Other:
Required
Ethnicity
*
Hispanic or Latinx
Not Hispanic or Latinx
Required
Are you experiencing COVID-19 symptoms?
*
Yes
No
Next
Page 1 of 10
Never submit passwords through Google Forms.
This form was created inside of Kirk's Pharmacy.
Report Abuse
Forms
