Covid-19 Testing Information Request Form

Name

Phone

Email Address

Address

Possible Exposure Possible ExposurePeace of mindI have been experiencing symptoms

When were you exposed? (If not sure, then give an approximate time)

Which symptoms have you been experiencing? If you are having an emergency contact EMS or call 911. Which symptoms have you been experiencing? If you are having an emergency contact EMS or call 911. Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea

What type of test are you looking for? (Select all that apply) What type of test are you looking for? (Select all that apply) COVID - Rapid Result/Instant Test COVID - PCR Test Unsure (Please Call)

Please bring proof of insurance and a valid photo ID (driver's license). If you don't have insurance please bring a valid photo ID and your Social Security card. Please bring proof of insurance and a valid photo ID (driver's license). If you don't have insurance please bring a valid photo ID and your Social Security card. I understand

How many tests? How many tests?12-34-56-78-1010+ (We will contact you for more details)

Are you setting up Covid Testing for your company? (If yes, we will contact you to complete set-up) Are you setting up Covid Testing for your company? (If yes, we will contact you to complete set-up) Yes No

How did you hear about us? How did you hear about us?LinkedInFacebookInstagramTikTokTwitterReferralOther

Who referred you? (We would love to give them a big thanks!)

Through who or what? (We would love to give them a big thanks!)