CIMPAR Covid-19 Testing and Treatment

CIMPAR Covid-19 Testing and Treatment

Initial Intake Form

Patient Information

Patient's First Name*

Patient's Last Name*

Date of Birth*

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?

Select or enter value

Which test are you looking for?

Select or enter value

Are you experiencing any symptoms?

Select or enter value

When did your symptoms start?

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?

Select or enter value

Are you experiencing symptoms?

Select or enter value

When day your symptoms start?

Send me a copy of my responses

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