COVID-19 Testing

COVID-19 Testing Registration & Consent Form


    First Name

    Last Name





    Phone Number




    Street Address
    Street Address Line 2



    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