Fill Out This Screening Form and Submit It Before Your Test is Taken. 

Call (908) 452-5612 when you have finished this form and are waiting in the car, ready for your COVID-19 Test.

If you are unable to complete the form online, click here to print our printer-friendly version.

COVID-19 Screening

COVID-19 Screening

This form must be completed before getting a COVID-19 test.

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
Last
Relationship to Patient
Parent/ Guardian Name
Parent/ Guardian Name
First
Last
Patient Sex
Patient Race
Patient Ethnicity
Have you experienced any of these symptoms? (Select any that apply) *
Do you have any of the following medical conditions? (Select any that apply) *
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)
Is this your first time taking the COVID-19 test?
Have you previously tested positive for COVID-19?
How Did You Hear About Us? *
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. *
I acknowledge that I have answered these questions truthfully to the best of my knowledge.