TEST patient agreement form

First Name *

Last Name *

Do you have a fever or above normal temperature?

Have you had shortness of breath or had trouble breathing?

Do you have a dry cough?

Do you have a runny nose?

Have you recently lost or had a reduction in your sense of smell?

Do you have a sore throat?

Have you been in contact with someone who has tested positive for COVID-19?

Have you tested positive for COVID-19?

Have you been tested for COVID-19 and are awaiting results?

Have you traveled outside the United States by air or cruise ship within the past 14 days?

Have you traveled within the United States by air, bus, or train within the past 14 days?