Patient Intake Form

Please fill out the following form.

First name

Last name

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

Date of birth

Month

Day

Year

Have you recently traveled internationally or to any high-risk areas within the past 14 days?

No

Yes

Are you currently experiencing any COVID-19 symptoms? (e.g., fever, cough, difficulty breathing, loss of taste or smell)

No

Yes

If you answered yes to any of the questions above, please supply additional information.

I declare that the info I’ve provided is accurate and complete.

Upload front of ID

Upload Back of ID

Upload Lab Order

Signature

Signature field is empty.

Intake Form