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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

1.First name:(Required.)

2.Last name:(Required.)

3.What is your gender?(Required.)

Female

Male

Other (please specify)

4.Date of birth (MM/DD/YYYY):(Required.)

5.Email address:(Required.)

6.What is the address where you currently live?(Required.)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

7.What is your cell phone number? (Required.)

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