COVID-19 Risk Assessment

1
Are you seeking testing for COVID-19 ?* This field is required.
YESNO
2
Which symptoms are you experiencing?* This field is required.
cough
fever
difficulty breathing (severe cases)
been in contact with a someone with a positive COVID-19 test
diarrhea
muscle aches, headaches, or chills
not experiencing symptoms
3
Do you work in a high risk environment ( hospital, paramedic, grocery store, etc)* This field is required.
YESNO
4
Do have heart disease, HTN, diabetes, COPD, obesity, or over age 70?? * This field is required.
YESNO
5
Have you checked your temperature?* This field is required.
Below 98.6 F
Above 100 F
Above 103 F
6
Name* This field is required.
7
Thank you {name},

We are going to help get you a testing at Clear Medical Concepts ASAP.

Right now, it is important to isolate yourself as best possible. Keep social distance and be conscience of time in spent in groups. Hang in there and practice good hygiene.

Seek prompt medical attention if your illness is worsening (e.g., difficulty breathing).

If you do not wish to be tested at our facility contact your PCP and alert them of your current symptoms and we will pass along your symptoms and first names onto local and state Health Departments to assist with the needs for more testing.
8
Age* This field is required.
21-40
Please Select
infant-20
21-40
41-60
61-80
80+
9
Phone Number* This field is required.
10
Zip Code* This field is required.
11
Email* This field is required.
Should be Empty: