Surveypoint

Q1

First Name

Name*

Q2

Middle Name

Name*

Q3

Last Name

Name*

Q4

Sex*

Female

Male

Other

Q5

Date Of Birth*

Q6

Cell/Phone #*

Q7

Email*

Q8

Ethnicity*

HISPANIC

NON-HISPANIC / LATINO

DECLINE

Q9

Race*

WHITE

BLACK / AFRICAN AMERICAN

ASIAN / PACIFIC ISLANDER

OTHER

UNKNOWN

DECLINE

Q10

Street Address

Address*

Q11

Street Address Line 2

Address*

Q12

City

Address*

Q13

State / Province

Address*

Q14

Postal / Zip Code

Address*

Q15

Exam Request*

PCR Nasal Swab

Rapid Antigen

Antibody Blood Finger prick

Q17

Test Location*

Please Select

Olympic

Lincoln

Pico

Farifax

Q18

May we phone, email or send a text to you to confirm appointments?*

Yes

No

Q19

May we leave a message on your answering machine at home or on your cell phone?*

Yes

No

Q20

May we discuss your medical condition with any member of your family?*

Yes

No

Q21

If YES, please name the members allowed:

Q22

Eazy Testing Inc -Form Fill

First Name

Middle Name

Last Name

Sex*

Date Of Birth*

Cell/Phone #*

Email*

Ethnicity*

Race*

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Exam Request*

Test Location*

May we phone, email or send a text to you to confirm appointments?*

May we leave a message on your answering machine at home or on your cell phone?*

May we discuss your medical condition with any member of your family?*

If YES, please name the members allowed:

Patient Signature*