CIMPAR Covid-19 Testing and Treatment

Initial Intake Form

Patient Information

Patient's First Name

Patient's Last Name

Date of Birth

mm/dd/yyyy

Phone Number

Phone

Street Address

City

Zip Code

Covid Testing

Respond to the following questions if you are seeking Covid-19 testing. If you are Covid-19 positive you will have the opportunity to see a provider for treatment. If you have already tested positive and are seeking treatment skip to Covid Therapeutics below.

Have you tested positive for Covid-19?

Which test are you looking for?

Are you experiencing any symptoms?

Covid Therapeutics

Respond to the following questions if you have already tested positive and are seeking Covid-19 Treatment.

Which treatment are you interested in?

Are you experiencing symptoms?

Send me a copy of my responses

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