Primary Information - COVID-19 Checkup
The following information is going to help us qualify you and give you the best treatment possible.
Full Name
*
First Name
Middle Name (optional)
Last Name
What is your phone number?
*
-
Area Code
Phone Number
What is your Date of Birth?
*
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Year
Please select your Sex.
*
Male
Female
Please specify your gender.
*
Male
Female
Please enter your ethnicity.
*
What is your Address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
Confirmation Email
It's crucial we have the correct email for your account.
What is the name of your employer?
*
Date
*
-
Month
-
Day
Year
This field is locked by default.
Please accept the following agreements so we can proceed with your medical visit.
*
I agree to the
Privacy Policy
,
Terms and conditions
, and
Telehealth Consent
.
Do we have permission to text or call you?
*
Yes
No
Do we have permission to access your medical history from 3rd party sources?
*
Yes
No
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Next
Medical History
Please give us a a background of your medical history so we can better assist you.
Do you have any of the following?
*
COPD
Kidney or Liver Disease
Heart Disease
Diabetes
Neurologic Issues
Immunocompromised
Asthma
Substance Abuse
Currently Pregnant
No, none of the above options apply to me.
Do you use nicotine?
*
Yes
No
Previous nicotine user
Do you have any medical conditions?
*
Yes
No
Please list your medical conditions below
*
Include even any minor or recent conditions or symptoms. We need to know your full history to give you the best care. Even include things you think you have whether or not it's been diagnosed by your doctor. We will call or message you if we need more information.
Please enter any Medications you are currently taking.
Please enter any known allergies you have.
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COVID-19 Symptoms
Please give us some more information so we can give you the best possible medical advice.
Are you looking to schedule an online appointment (video chat) to discuss your symptoms, or looking for an in-person test at a clinic?
*
Online-Appointment
In-person COVID-19 test
Which type of COVID-19 test would you like to receive?
*
Test for travel with no symptoms (Swab test)
Rapid COVID-19 test
Have you experienced any of these symptom's not caused by another condition?
*
Fever
Felt Feversish
Cough
Chills
Shortness of Breath
Abdominal Pain
Nausea
Diarrhea
Muscle Aches
Sore Throat
Runny Nose/Nasal Congestion.
Headache
Loss of taste or smell
Fatigue
Wheezing
Chest Pain
Vomiting
No, I have not experienced any of these symptoms not caused by another condition.
Have you had/done any of the following?
*
Known contact with COVID-19
Recent travel
Contact with a Healthcare worker
Recently been in a Healthcare facility
Previously positive for COVID-19
No, none of these options apply to me.
Where did you come in contact with a Healthcare worker?
*
Have you been in contact with someone within the last 14 days that has tested positive for COVID-19 or had COVID-19 related symptoms? Contact involves any activity with another person that was closer than 6 feet in distance from you for more than 5 minutes without a mask or when touching shared items. This includes any contact with fluids, such as being sneezed on or coughed on.
*
Yes
No
What contact did you have with this person? Please be as detailed as possible.
*
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COVID-19 Form Submission
Once your form is submitted a doctor will reach out to you shortly!
Will you use insurance to help pay for your consultation or test? You can use your insurance, or if you don't have insurance we can help you find low cost options.
*
Yes
No, don't have insurance
No, I don't want to use insurance
I'm not sure
Please upload pictures of your insurance card
HERE
if you have them available.
Please upload a picture of the front of your insurance card.
*
Browse Files
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of
Please upload a picture of the back of your insurance card.
*
Browse Files
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of
Submit
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