FreeCovidTesting.org Questionnaire 

In order to register for the COVID-19 Antibody test, we'll need to ask you a series of questions. Make sure to have a valid form of id (driver's license or government id) and your insurance card (if applicable) on hand for this registration. 

If you have any questions please call us at 888-501-2707

BEFORE YOU START, IF YOU ARE EXPERIENCING ANY OF THESE SYMPTOMS, STOP AND CALL 911:
- Constant chest pain or pressure
- Extreme difficulty breathing
- Severe, constant dizziness or light-headedness
- Slurred speech
- Difficulty waking up

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* 1. First name:

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* 2. Last name:

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* 3. What is your email address?

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* 4. What is your phone number?

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* 5. Upload a photo of your driver's license or government-issued id (front side).

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 6. Do you currently have health insurance

 
 50% of survey complete.

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