Rapid COVID-19 Testing Appointment Form First Name*Last Name*Email*Cell Phone*Tel. HomeAddress*City*Date of Birth*Gender*MaleFemaleEthnicity*HispanicNon-HispanicRace*WhiteBlackAsian/PIAm Indian/Alaskan Native2 or more raceOtherTravel and exposureAre you seeking a test to prevent possible spread of COVID-19 for future travel or recreation?*YesNoAre you seeking a test to prevent possible spread of COVID-19 after being at a place where social distancing was not possible?*YesNoHave you had close contact with someone with a confirmed case of COVID-19?*YesNoAre you a resident in a special setting where the risk of COVID-19 transmission may be high?*YesNoSeparator2Splitter1WORKPLACE RISKSDo you work in health care?*YesNoDo you work in a special setting where the risk of COVID-19 transmission may be high?*YesNoSeparator1Medical HistoryHave you been asked or referred to get tested by a health care provider?*YesNoHave you experienced any symptoms in the last 14 days?*YesNoIf Yes, you have an experienced in last 14 days please mentioned you symptomsSplitter2Federal Government mandated questionsHave you received a COVID-19 vaccine?*YesNois this your first time taking COVID-19 test?*YesNoDo you have any medical conditions?*YesNoIf applicable, are you currently pregnant?YesNoI don't know-*I acknowledge that I have answered these questions truthfully to the best of my knowledge.Submit Error occured. Please confirm your data and submit again: