Date
*
/
Month
/
Day
Year
Date
Name
*
First Name
Middle Initial
Last Name
DOB
*
/
Month
/
Day
Year
Date
Age:
*
Sex:
*
Male
Female
Address
*
Address
Street Address Line 2
City
State
Zip
Cell Phone#:
*
Please enter a valid phone number.
Your Race / Ethnicity
*
White
Black
Hispanic
Asian
Pacific Islander
Other
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Please answer the following Covid related health questions.
Any recent contact with Covid infected person(s)
*
Yes
No
Have you recently been tested at other facility or testing site?
*
Yes
No
Is this your first Covid test?
*
Yes
No
Do you currently live in a care facility setting?
*
Yes
No
Do you work in a health care setting?
*
Yes
No
What is your occupation?
Current Symptoms -- Please select symptoms that you have
*
No symptoms currently
Have symptom(s) below
Fever
Chills
Fatigue
Body ache
Headache
Sinus congestion
Sinus pressure
Sore throat
Loss of sense of smell
Loss of sense of taste
Cough
Short of breath
Chest tightness
Stomach pain
Diarrhea
Nausea
Vomiting
When did your symptom(s) start?
*
-
Month
-
Day
Year
Date
Current Medical Problems -- Please select problems that you have
*
No medical problems
Diabetes
Obesity
Asthma
COPD
History of heart attack
Congestive heart failure
Kidney disease
Liver disease
Blood disorder
Cancer
On cancer treatment now
On steroid now
Bone marrow transplant
Organ transplant
HIV
Currently on immune drugs
What kind of cancer are/were you diagnosed with?
Tobacco use?
*
Yes
No
Alcohol use?
*
Yes
No
Allergy
No Medication allergy
Yes
What medications are you allergic to:
Current Medications:
None
Medications taken:
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Upload or Take a picture of your Driver License OR a State ID -- PLEASE MAKE SURE THE PHOTO IS CLEAR BEFORE SUBMITTING (otherwise we cannot read). You can retake multiple times before submitting.
*
Browse Files
Drag and drop files here
Choose a file
PLEASE MAKE SURE THE PHOTO IS CLEAR BEFORE SUBMITTING (otherwise we cannot read). You can retake multiple times before submitting.
Cancel
of
How will we be billing today's visit?
*
Please Select
Use Labcorp - (office visit required) Insurance
Cash / Credit Card
Membership
Upload or Take a picture of the FRONT of your Insurance Card
Browse Files
Drag and drop files here
Choose a file
PLEASE MAKE SURE THE PHOTO IS CLEAR BEFORE SUBMITTING (otherwise we cannot read). You can retake multiple times before submitting.
Cancel
of
Upload or Take a picture of the BACK of your Insurance Card
Browse Files
Drag and drop files here
Choose a file
PLEASE MAKE SURE THE PHOTO IS CLEAR BEFORE SUBMITTING (otherwise we cannot read). You can retake multiple times before submitting.
Cancel
of
Please describe the car you will be in:
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Next Step -- You will be connected to our EMR portal. Fill out Section 1 and 2, then SKIP to Section 6 to sign and finish.
Proceed to Finish Registration
Should be Empty: