Coronavirus Survey
Please complete the following survey.

Once submitted, you will be able to schedule your COVID-19 test appointment.
Email address *
First & Last Name *
Phone Number *
Insurance Company *
Insurance ID Number *
Billing Address *
Date of Birth *
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Today's Date *
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Check if you have had any of the following *
Required
List any medications you are on: *
List any allergies you have: *
List any vitamins/herbs/minerals you are taking: *
Have you been within 6 feet of a person with a confirmed case of COVID-19? *
Have you been in contact with anyone who has been around someone with a confirmed case of COVID-19? *
In the last 48 hours, have you had any of the following NEW symptoms? *
Required
Do you have any of the following possible emergency symptoms? *
Required
Has a public health official advised you to get tested for COVID-19? *
Do you have any reason to believe you have been exposed to or acquired COVID-19? *
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days? *
Have you or anyone in your household traveled in the US in the past 21 days? *
Have you or anyone in your household traveled abroad in the last 21 days? *
Are you or anyone in your household a health care provider or emergency responder? *
Is there anything else we should know about your reason for coming in for a COVID-19 test?
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