Aliso Viejo Coast Hills Church Partners with GUARDaHEART Foundation - March 2021

To Offer COVID-19 Rapid Antigen Test and No Cost COVID-19 Antibody Blood Test Dates: March 9, 16, 18, & 23, 2021 Time: 9:30 am to 2:15 pm Location: 5 Pursuit, Aliso Viejo, CA 92656

First Name*

Middle Intial

Last Name*

Do you have:*

- A fever of 100.4 degrees Fahrenheit/38-degree celsius or higher - A cough - Shortness of breath or difficulty breathing - Chills - Muscle pain - Sore throat - New loss of taste or smell - Congestion or Runny Nose - Nausea - Diarrhea

Yes

COVID Questionnaire Answer

Based on the answers you provided you might be infected with COVID-19. Please contact your primary care physician's office. If you don't have a primary care physician please provide your name, address, and contact information and we will see if one of our physicians is in your area.

Have you traveled in the past 14 days to regions affected by COVID-19?*

Yes

Have you previously received a COVID-19 vaccine?*

Yes

Have you received only your first dose or both dose of the COVID-19 vaccination?*

Only First Dose

Both First and Second Dose

Date of First Dose*

Date of Second Dose*

Have you been in close contact with anyone who has a confirmed COVID-19 diagnosis?*

Yes

Gender*

Month of Birth*

Select

Date of Birth*

Select

Year of Birth*

Select

Address*

City*

State*

Select or enter value

ZIP Code*

Phone #*

Email*

Primary Health Insurance Type*

If you have no insurance please select " Covid-19 Uninsured". The CARES Act has ordered health insurance companies to pay for COVID-19 Antibody Blood test in full, with no-out-of pocket cost to patients with health insurance. Additionally, the Families First Coronavirus Response Act (FFCRA) has been established health plans to reimburse for COVID-19 testing for the uninsured.

Upload your Insurance Card*

Please click on "browse files" below to take a photo or upload a copy of the front and back of your insurance card.

Drag and drop files here or

Comorbidity Questions

These questions are optional but important because your physician needs to know if you have any of these to better counsel you about COVID-19 virus infections.

Race*

Please select the best one that applies. White (Europe, Middle East, North) Asian (Far East, Southeast Asia, Indian) American Indian or Alaska Native (North, South, and Central America) Native Hawaiian or Other Pacific Islander (Hawaii, Guam, Samoa, or other Pacific Islands)

Ethnicity*

Hispanic or Latino

Not Hispanic or Latino

Not Disclosed

Smoker*

Yes

Diabetic*

Yes

Family History of Heart Attack*

Family History of Heart Attack, Stroke, Angina, Coronary Artery Bypass or a Stent ≤ 65 years of age (Parent/Sibling/Child)

Yes

Patient History of Heart Attack*

Yes

Diabetes Medication*

Yes

Lipid Lowering Medication*

Yes

Hypertension*

Yes

Blood Pressure Medication*

Yes

Excessive Stress*

Yes

What Test would you like to order?

To get 1003 PULS (Protein Unstable Lesion Signature) you need to be at least 20 years old.

Please select all test that apply.*

Select

Send me a copy of my responses

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