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COVID-19 Screening Questionnaire
To safeguard you and your environment please fill out the following form for testing and obtaining results
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* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Time
*
Time
:
AM
PM
First Name, Middle Initial (M.I), Last Name
*
Your answer
Gender
*
Male
Female
Other
Prefer not to say
Required
Date of Birth
*
MM
/
DD
/
YYYY
Street Address (Include Apt #):
*
Your answer
City:
*
Your answer
State:
*
Your answer
Zipcode:
*
Your answer
Email:
*
Your answer
Phone Number:
*
Your answer
Race:
*
American Indian and Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White
Hispanic or Latino
Unknown
Ethnicity:
*
Hispanic or Latino
Not Hispanic or Latino
Unknown
Do you have Health Insurance?
Yes
No
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