COVID 19

If you are requesting to be seen for COVID symptoms and/or testing, please complete the below form. Once the form is submitted, a member of our team will be in touch with you on scheduling a time for you to be seen.

Contact Information

Name:

Preferred phone:

Birth date:

Vehicle:

Primary Doctor:

Preferred pharmacy:

Insurance:

Mailing address:

City:

State:

Zip:

Preferred clinic:

Symptoms

Please mark any symptoms.

Cough:

Productive

Dry

None

Fever:

Yes

When did your symptoms start?:

Are you taking any medication for your symptoms?:

Yes

Additional Questions

Do you have any respiratory illness, such as Asthma or COPD?:

Yes

Do you Smoke:

Yes

Where do you work/Attend school:

Last day at work?:

School activities:

Have you had any recent travel?:

Yes

Exposure to large crowds?:

Yes

Have you had any close contact with a person that has a confirmed COVID-19 case?:

Yes

What medications are you currently taking?:

Medication allergies:

Past medical history:

Last flu vaccine received:

Yes

Covid vaccine received:

Yes

Booster received:

Yes