Step 1

Step 1

Personal Details

Patient Ethnicity
I consider myself: *
Patient Race
Which of the following racial designations best describes you (select one or more): *
Do You Have Insurance?
If you Don't have Insurance, Fill this CARES ACT Consent Form

Step 3 Title

Insurance / Payment Details

Do you have insurance? *
How will you be paying? *

Step 4 Title


I have following condition(s): *
I have a condition that weakens my immune system or makes it harder to fight infections: *
I am taking one of these medications: *
I am or may be pregnant
I regularly use tobacco or nicotine products (e.g. cigarettes, e-cigarettes, vapes, hookah, etc.)
Have you possibly been exposed to the Coronavirus in the past 2 weeks? *
Yes, I have been in close proximity (within 6 ft.) to someone who has been diagnosed with or presumed to have COVID-19. *
Yes, I have been in close proximity (within 6 ft.) to someone who is sick but has not been diagnosed with COVID-19. *
Yes, I live, work or have visited a place where COVID-19 is widespread. *

Step 5 Title


Have you had any of the following symptoms since December 2019: *
Are you currently experiencing any of these symptoms? *

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