COVID-19 Testing Pre-Registration
First Name:
Last Name:
Date of Birth (mm/dd/yyyy):
Sex:
Male
Female
Address 1:
Address 2:
City:
County:
State:
Zip:
Email:
Phone:
Race:
White
Black
Multi
Other
Hispanic:
No
Yes
Pregnant:
No
Yes
Please choose an approximate appointment date & time:
10/04/2023 9:00 AM
10/04/2023 10:00 AM
10/04/2023 11:00 AM
10/04/2023 12:00 PM
10/04/2023 1:00 PM
10/04/2023 2:00 PM
10/04/2023 3:00 PM
10/04/2023 4:00 PM
10/05/2023 9:00 AM
10/05/2023 10:00 AM
10/05/2023 11:00 AM
10/05/2023 12:00 PM
10/05/2023 1:00 PM
10/05/2023 2:00 PM
10/05/2023 3:00 PM
10/05/2023 4:00 PM
Are you currently symptomatic?:
No
Yes
Have you been in contact with anyone that has tested positive in the last 10 days?:
No
Yes
Are you fully vaccinated (including booster dose)?:
No
Yes
