In-Home Testing Form Patient Info Name * First Middle Name Middle Last Name * Last Date Of Birth * Gender * FM Phone * Email * Address * Address Address Address City City State California Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip/Postal Zip/Postal ID Type Driver LicensePassport #Other ID Type ID Number * Driver License / Passport - Attach a file Drop a file here or click to upload Choose File Maximum upload size: 314.57MB Patient Covid-19 Screening Questionnaire Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.) * Fever (100.4° F/37.8° C or greater as measured by an oral thermometer) * Yes No Cough * Yes No New loss of taste or smell * Yes No Shortness of breath or difficulty breathing * Yes No Chills * Yes No Head or muscle aches * Yes No Nausea, diarrhea, vomiting * Yes No In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? * Yes No In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? * Yes No Traveled in the last 14 days? * Yes No Message or Comment I have read and agree to the terms and conditions. * I agree reCAPTCHA If you are human, leave this field blank. Submit
