Business Name

Business Address

Business Phone

Contact Name

Contact Phone

Contact Email

Approximate number of tests

How often will you need testing?

How soon do you need testing?

What times for testing works best for you? What times for testing works best for you? Morning Mid-Day Afternoon Any

What days for testing works best for you? What days for testing works best for you? Monday Tuesday Wednesday Thursday Friday Any

Are you requesting testing to be performed at multiple locations or one location? Are you requesting testing to be performed at multiple locations or one location? One location per day Multiple locations per day

Location Name

Address

City

Zip

Number of tests on location

Ideal time spent at location

Location Name

Address

City

Zip

Number of tests on location

Ideal time spent at location

Location Name

Address

City

Zip

Number of tests on location

Ideal time spent at location

Location Name

Address

City

Zip

Number of tests on location

Ideal time spent at location

Location Name

Address

City

Zip

Number of tests on location

Ideal time spent at location

Location Name

Address

City

Zip

Number of tests on location

Ideal time spent at location

Location Name

Address

City

Zip

Number of tests on location

Ideal time spent at location

Location Name

Address

City

Zip

Number of tests on location

Ideal time spent at location

Location Name

Address

City

Zip

Number of tests on location

Ideal time spent at location

Location Name

Address

City

Zip

Number of tests on location

Ideal time spent at location

Location Name

Address

City

Zip

Number of tests on location

Ideal time spent at location

First Name*

Last Name*

Date of Birth (MM/DD/YYYY)*

Gender* Gender*MaleFemaleOtherDecline to answer

Race* Race*Black / African AmericanAsianNative Hawaiian / Pacific IslanderAmerican Indian / Alaska NativeOther / Refuse to answer

Ethnicity* Ethnicity*Hispanic or LatinoNot Hispanic or LatinoOther / Refuse to answer

Address*

City*

State*

Zip*

Phone*

Email Address*

Email Address*

What test are you requesting? * What test are you requesting? * PCR Rapid (Molecular/Antigen) Unsure

What is your reason for requesting testing? * What is your reason for requesting testing? * COVID19 Screening Possible Exposure Known Exposure

Exposure Date (MM/DD/YYYY)

Do you currently have any of the following symptoms? * Do you currently have any of the following symptoms? * Fever of 100.4°F or feeling feverish New or worsening dry cough Muscle pain Nausea, vomiting, or diarrhea Fatigue Sore throat Headache Runny nose Repeated shaking with chills Shortness of breath or difficulty breathing New loss of taste or smell None of the above

Date Symptom Began (MM/DD/YYYY)

Do you have insurance? * Do you have insurance? * Yes No

Insurance Name

Insurance Subscriber ID

Insurance Group #

Are you the primary subscriber?* Are you the primary subscriber?* Yes No

Primary subscriber Name

Primary subscriber DOB

Is primary subscriber home address the same as patient?* Is primary subscriber home address the same as patient?* Yes No

Address

City, State & Zip