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:
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