Covid 19 Testing Name* First Last Email Phone Number*Sex* Male Female Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you over 18?* Yes No If you are scheduling for someone other than yourself, please acknowledge you the parent or legal guardian of the person who is named on this form.* I am the parent or legal guardian of this person. N/A - I am over the age of 18 Symptoms* R50.9 I have a fever R50 I have a cough R06.02 I have shortness of Breath R43.9 I have loss of smell and taste Z20.828 I believe I have been exposed to COVID-19 Z03.818 I am over the age of 60 Other Symptoms*College Required Testing: list college name:Are You Employed?* Yes No First Test?* Yes No Unknown Hospitalized* Yes No Unknown ICU Resident of group home setting?* Yes No Unknown Pregnant?* Yes No Unknown Race?* American Indian Asian African American Hawaiian White Ethnicity?* Hispanic/Latino Non-Hispanic/Latino Primary Language* English Spanish ASL Testing Schedule Date* MM slash DD slash YYYY CAPTCHA
