Provider Code:
First Name* must provide value
Last Name* must provide value
Date of Birth* must provide value
M-D-Y
patient age View equation
Date of birth is in the future, please enter a valid date of birth
Sex* must provide value
Female
Male
Not Provided
Please fill out the parent/guardian information Guardian First Name
Guardian Last Name
Guardian DOB Today M-D-Y
Guardian Phone
Ethnicity* must provide value
Hispanic or Latino NOT Hispanic or Latino Unknown Not Reported Hispanic or Latino
NOT Hispanic or Latino
Unknown
Not Reported
Race* must provide value
Asian Black or African American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native White Other Race Unknown / Not Reported Asian
Black or African American
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
White
Other Race
Unknown / Not Reported
Street Address* must provide value
City* must provide value
State* must provide value
Utah Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code* must provide value
Phone number* must provide value
Include Area Code
Please provide the email where you would like test results sent. The email provided will be used to send a secure email containing results from the test.
* must provide value
Confirm Email Address:* must provide value
cemail View equation
Email addresses do not match, in order to receive your test result over email you must confirm your email address.
Individual Type Patient/Resident
Healthcare Worker
Staff Member
Visitor
Patient/Resident
Healthcare Worker
Staff Member
Visitor
Exposure risk category - Healthcare Worker/Staff
Use the picture below to help determine risk. Please ask your facility administrator to help you determine your risk level if uncertain.
Exposure risk category
Use the picture below to help determine risk. Please ask your facility administrator to help you determine your risk level if uncertain.
Exposure Risk Low
Higher
No known risk
Are you pregnant? Yes
No
Is this the first time you have been tested for COVID-19?* must provide value
Yes
No
Unknown
Are you employed in healthcare?* must provide value
Yes
No
Have you been in close contact with someone who tested positive for COVID-19 in the last two weeks?-Close contact means you were closer than 6 feed or 1 meters (about 2 arms lengths) to the person who tested positive for a total of 15 minutes or longer while he or she was infectious. A person is infectious up to 2 days before they develop symptoms or test positive.
Yes
No
Unknown
Do you have any of the following symptoms? Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea
* must provide value
Yes
No
Unknown
Do you have any of the following symptoms? Check all that apply
* must provide value
Fever or chills cough shortness of breath or difficulty breathing fatigue muscle or body aches headache new loss of taste or smell sore throat congestion or runny nose nausea or vomiting, diarrhea Fever or chills
cough
shortness of breath or difficulty breathing
fatigue
muscle or body aches
headache
new loss of taste or smell
sore throat
congestion or runny nose
nausea or vomiting, diarrhea
Were you hospitalized because of COVID-19?* must provide value
Yes
No
Were you admitted to the ICU because of COVID-19?* must provide value
Yes
No
Are you a resident in a congregate care setting?(including nursing home, residential care for people with intellectual and developmental disabilities, psychiatric treatment facility, group home, board and care home, homeless resource center, foster care or other setting)
* must provide value
Yes
No
If you would like to receive your test result over email, please confirm your email address.
I consent to receive my COVID-19 test result through a secure email. If I do not consent, I can receive a paper result at the testing location. I Consent
I DO NOT Consent
I Consent
I DO NOT Consent
Please read carefully:* must provide value
I consent (for myself) I consent for my minor child I don't consent I consent (for myself)
I consent for my minor child
I don't consent
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