Registration for COVID Testing – FREE COVID TESTING CENTERS | NATIONWIDE SEARCH

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Registration for COVID Testingcovidtesting2021-01-07T23:51:48+00:00

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PERSONAL DETAILS
Name*
First Last
Phone*
Email
Gender*
Date of Birth*
Date Format: MM slash DD slash YYYY
License / ID State*
License / ID Number*
Address*
Street Address Address Line 2 City State ZIP Code
Type of Test

MEDICAL SYMPTONS
Are you experiencing any of the following symptoms? (Select all that apply)*
- I am not experiencing any symptoms
- Body Aches and Pains
- Fever
- Sore Throat
- Cough
- Congestion
- Difficulty Breathing
- Diarrhea
- Vomiting
- Headache
- Loss of taste/smell
- Repeated shaking with chills
- Chills
- Muscle aches
What date (if any) did your symptoms begin?
Date Format: MM slash DD slash YYYY
Do you have a known exposure to a person confirmed to have COVID-19?*

MEDICAL CONDITIONS
Do you have any of the following conditions? (Select all that apply)
- Asthma or Chronic Lung Disease
- Heart Disease
- Extreme Obesity
- Pregnancy
- Hypertension
- Suppressed immune system (e.g. cancer, HIV)
- Liver Disease
- Kidney Failure or End Stage Renal Disease

INSURANCE COVERAGE
The Families First Coronavirus Response Act ensures that COVID-19 testing is free to anyone in the U.S., including the uninsured, and zero co-pay for those with health insurance.
Do you have insurance coverage?*
Social Security Number*
Insurance Company*
Insurance Phone*
Insurance Policy Number*
Group Number
Insured Name
First Last
Insurance Responsible Party (name, address, phone number)
Accepts Terms and Conditions (HIPAA)*
- Accepts Terms and Conditions (HIPAA)
By checking this box and submitting your information, you acknowledge your understanding and accept the Terms and Conditions (HIPAA).

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