TEST patient agreement form Please enable JavaScript in your browser to complete this form.First Name *Last Name *Do you have a fever or above normal temperature?YesNoHave you had shortness of breath or had trouble breathing?YesNoDo you have a dry cough?YesNoDo you have a runny nose?YesNoHave you recently lost or had a reduction in your sense of smell?YesNoDo you have a sore throat?YesNoHave you been in contact with someone who has tested positive for COVID-19?YesNoHave you tested positive for COVID-19?YesNoHave you been tested for COVID-19 and are awaiting results?YesNoHave you traveled outside the United States by air or cruise ship within the past 14 days?YesNoHave you traveled within the United States by air, bus, or train within the past 14 days?YesNoPhoneSubmit
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