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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

    Signature