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Covid 19 Testing -Form Fill

Section One
Q1

Full Name*

First Name
Q2

Full Name*

Last Name
Q3

Date of Birth*
Q4

Gender*
Q5

Phone Number*

Phone Number
Q6

Email*
Q7

Address*

Street Address
Q8

Address*

Street Address Line 2
Q9

Address*

City
Q10

Address*

State / Province
Q11

Address*

Postal / Zip Code
Q12

Primary Insurance
Q13

Policy Number
Q14

Group Number
Q15

Do you have a history of, or currently have, any of the following health conditions? (Check all that apply)
Q16

PAST MEDICAL HISTORY Do you have any other chronic medical conditions (in addition to those above)?*
Q17

Do you have any medication allergies?*
Q18

Are you currently taking any medication?*
Q19

Do you currently smoke or use tobacco products?*
Q20

In the past 14 days have any? (Check all that apply)*
Q21

In the past 14 days, have you had close contact (< 6 feet for >15 minutes) with anyone with the following? (Check all that apply)
Q22

Signature*