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Jan 16, 2021 Crested Butte COVID-19 Community Testing Registration
Please complete this form for the day you will be getting tested.
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* Indicates required question
The Last 4 Digits of Your Social Security Number
*
Your answer
First Name
*
Your answer
Middle Initial
Your answer
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Sex Assigned at Birth
*
Male
Female
Unknown
Other
Not applicable
Ambiguous
Intersex
Prefer Not to Say
Race
Native Hawaiian_Pacific Isl
White
Black
American Indian/Alaskan Native
Latino
Asian
Other
Clear selection
Ethnicity
Not Hispanic
Hispanic
Unknown
Clear selection
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Which symptoms are you experiencing?
*
Fever over 100.4F
Felt Feverish
Chills
Muscle Aches
Headache
Runny Nose
Sore Throat
Cough
Fatigue
Diarrhea
Nausea or Vomiting
Shortness of Breath
Abdominal Pain
Loss of Taste or Smell
Increased Need for Oxygen
NONE
Required
Symptom Onset Date
MM
/
DD
/
YYYY
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