Testing Site

2. Are you currently experiencing COVID-19 like symptoms?*

   1. Yes
   2. No
4. Please select any of the COVID-19 symptoms listed that you are currently experiencing:*

   1. Fever/Chills &/or Muscle Aches
   2. Headache
   3. Unexplained Fatigue
   4. Loss of Taste or smell
   5. Cough, Sore Throat &/or Runny Nose
   6. Vomiting &/or Diarrhea
   7. None of the Above
   8. Other
6. Other symptoms not labled above:
8. When did your symptoms begin?*
   When did your symptoms begin?
10. Have you been tested for COVID-19 recently?*

    1. Yes
    2. No
12. If yes, what was the date?
    If yes, what was the date?
14. First Name*
15. Last Name*
17. Address1*
19. Address2
21. City*
22. State*
23. Zip*
25. Cell Phone*
26. Email*
Leave This Blank:


27. Submit

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