Language
English (US)
Spanish (Latin America)
COVID-19 Testing Intake Form
Full Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Where Do You Live?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Travel And Exposure
All fields are required unless market optional.
Are you seeking a COVID-19 test for travel or recreation purposes?
*
Yes
No
Have you been somewhere where social distancing was not enforced?
*
Yes
No
Have you had close contact with a confirmed case of COVID-19?
*
Yes
No
Do you live in a residence where COVID-19 infection could be high? (Group homes, senior living facilities, homeless shelters)
*
Yes
No
Place Of Employment Exposure Risks
All fields are required unless market optional.
Do you work in the healthcare or medical sector?
*
Yes
No
Do you work in an environment where COVID-19 infection could be high? (Correctional centers, senior living facilities)
*
Yes
No
Medical Background
All fields are required unless market optional.
Have you been referred for COVID-19 testing by a medical professional?
*
Yes
No
Are you currently experiencing symptoms of COVID-19?
*
Yes
No
Have you experienced any COVID-19 symptoms in the past two weeks?
*
Yes
No
What's The Right COVID-19 Test For You?
All fields are required unless market optional.
Which COVID-19 test option do you prefer?
*
PCR/NAAT Molecular Lab Test
Rapid-Results Antigen Test
Choose your preferred time/date (must be confirmed by our staff)
GET TESTED
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