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COVID Pre-Screen

How it Works

  1. Please complete registration and submit. *Form must be completed in its entirety or you will not be scheduled for testing.
  2. You will receive an email with a payment link to make your payment.
  3. Once payment is made you will receive a confirmation email.

COVID Patient Pre-screening Questionnaire

Has the person being tested been in contact with anyone suspected or confirmed with COVID 19?
YesNo
Is the person being tested having a medical procedure being performed in the next 7 days?
YesNo
In the last 72 hours has the person being tested experienced fever, coughing, sore throat, difficulty breathing, shortness of breath, wheezing, headache, muscle aches, stomach pains, vomiting or diarrhea?
YesNo
Patient Information
Sex
MaleFemale
Marital Status
SingleMarriedDivorcedSeparatedWidowed
Race
WhiteBlack or African AmericanAmerican IndianAsianNative AlaskanNative Hawaiian or Pacific IslanderMultiracialDecline
Ethnicity
Hispanic or LatinoNon-Hispanic or Latino
Emergency Contact
Cash Pay Consent and Release

View Cash Pay Consent and Release (PDF)
I have read the Consent and Release

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