YADA Covid-19 Testing Registration

-EACH INDIVIDUAL TESTING MUST FILL OUT A SEPARATE SURVEY IN ORDER TO BE TESTED

If you have any questions please email us at info@mydoctornow.net

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
 
INSTRUCTIONS - PLEASE READ BEFORE YOU START:

- Have your ID & Insurance card with you before you start the registration.
- If you do not have insurance, you can select that option and continue the registration.
- Please make sure to complete the entire registration process, including the last section title "Acknowledgements," which require you to sign electronically.
- You will see a Thank You message, once you have completed the survey.
- Late registrations will NOT be accepted.

Question Title

* 1. First name (person being tested):

Question Title

* 2. Last name (person being tested):

Question Title

* 3. Gender?

Question Title

* 4. Date of Birth (MM/DD/YYYY):

Question Title

* 5. Email address:

Question Title

* 6. What is the address where you currently live?

Question Title

* 7. Cell Phone Number - Important Updates

 
 25% of survey complete.

T