Appointment for Rapid Covid-19 Test -

Gender*

Male

Female

Ethnicity*

Hispanic

Non-Hispanic

Are you seeking a test to prevent possible spread of COVID-19 for future travel or recreation?*

Yes

No

Are you seeking a test to prevent possible spread of COVID-19 after being at a place where social distancing was not possible?*

Yes

No

Have you had close contact with someone with a confirmed case of COVID-19?*

Yes

No

Are you a resident in a special setting where the risk of COVID-19 transmission may be high?*

Yes

No

Do you work in health care?*

Yes

No

Do you work in a special setting where the risk of COVID-19 transmission may be high?*

Yes

No

Have you been asked or referred to get tested by a health care provider?*

Yes

No

Have you experienced any symptoms in the last 14 days?*

Yes

No

Have you received a COVID-19 vaccine?*

Yes

No

is this your first time taking COVID-19 test?*

Yes

No

Do you have any medical conditions?*

Yes

No

If applicable, are you currently pregnant?

Yes

No

I don't know

Rapid COVID-19 Testing Appointment Form