COVID-19 Testing

COVID-19 Testing Registration & Consent Form

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    First Name
    Last Name
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    *
    MaleFemaleOther
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    Phone Number
    *
    Email
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    Street Address
    Street Address Line 2

    City
    State

    Postal code

    Livermore, CaliforniaLos Angeles, CaliforniaPhoenix, ArizonaChicago, Illinois
    Specific Plan Name

    FeverChillsCoughShortness of Breath OR Difficulty BreathingFatigueMuscle OR Body AchesHeadacheNew Loss of Taste OR SmellSore ThroatCongestion OR Runny NoseNausea OR VomitingDiarrheaNO SYMPTOMS

    Person with COVID-19 who has symptoms (listed above) that had a positive test OR was diagnosis based on clinical symptomsPerson who has tested positive for COVID-19 but has not had any symptomsNone of above