COVID-19 Screening COVID-19 Screening This form must be completed before getting a COVID-19 test. Fill Out This Form & Submit It Before Your Test is Taken. If you are unable to complete the form online, click here to print our printer-friendly version. Call (908) 452-5612 when you have arrived for your COVID-19 Test. Please have your payment ready. Age 3-15: A parent or legal guardian needs to fill out this form and accompany the patient to visit. Age 16-17: A parent or legal guardian needs to fill out this form. All fields are required unless marked as optional. Patient Name * Patient Name First First Last Last Relationship to Patient * I am the patient I am the Parent of the Patient I am the Legal Guardian of the Patient Parent/ Guardian Name Parent/ Guardian Name First First Last Last Patient date of birth (mm/dd/yyyy) * Patient Age * Patient Sex * Male Female Other Patient Race * American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White or Caucasian Other Patient Ethnicity * Hispanic or Latino Not Hispanic or Latino Decline to Answer Address (P.O. Boxes are NOT a Valid Address). Include Apt Number if necessary. * City * State * New JerseyNew YorkAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew MexicoNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Phone * Email * Have you experienced any of these symptoms? (Select any that apply) * Chills Congestion or Runny Nose Cough Diarrhea Fatigue Fever Headache Muscle or Body Aches Nausea or Vomiting New Loss of Taste or Smell Shortness of Breath or Difficulty Breathing Sore Throat NO SYMPTOMS PRESENT Approximately what date did your symptoms begin? (If no symptoms, put "NOT APPLICABLE") * In the past 14 days, have you had known or suspected exposure to the SARS-CoV-2 virus or a COVID-19 patient? (e.g. been exposed to someone with COVID-19 or been in a large public gathering where exposure is suspected) * Yes No Ever tested positive for COVID? * Yes No Did you receive the COVID-19 vaccine? 2 Doses 1 Dose None How Did You Hear About Us? * Facebook Friend Referral Google search Google Reviews Referral Sign Yelp Word of Mouth Other Time and date of your COVID appointment * Valid ID or Driver's License Upload (or give at time of appointment) Click to upload your valid ID Choose Photo Maximum upload size: 104.86MB I will bring my valid ID or driver's license and form of payment at the time of my appointment. I am aware that I must pay $100 at the time of my appointment. I understand that I must perform my own nasal swab or bring someone to do it for me. If I have to cancel my appointment, I will call (908) 452-5612 at least 24 hours in advance. * Yes I acknowledge that I have answered these questions truthfully to the best of my knowledge. * Yes If you are human, leave this field blank. Submit Δ
