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Step 1 Title

Step 1

Personal Details

Set Password
  •   Your password must contain at least one lower letter.
  •   Your password must contain at least one uppercase letter.
  •   Your password must contain at least one Number (0-9).
  •   Your password must contain at least one Special Character.
  •   Space is not allowed.
  •   Your password must be between 6 and 30 characters.
  •   Passwords do not match.
Patient Ethnicity *
I consider myself: *
Patient Race *
Which of the following racial designations best describes you (select one or more): *
Next

Step 2 Title

Health Insurance Details

DISCLAIMER:  NO COST with Insurance. NO COST for California uninsured Residents.  Out-of Pocket for uninsured non CA Residents
Do You Have Insurance?*
Are You CA Resident?

Health Insurance Details

Out of Network Coverage?
Active Now?
Insurance Start Date *
Deductibles Met?
Co-Insurance (Supplemental Plan B, or Other)?

Upload State Identification / Government Issued ID Front *
Upload Government Issued ID Back*
Upload Insurance Front Side *
Upload Insurance Back Side *
If you Don't have Insurance, Fill this REQUISITION Form

Upload Insurance Back Side

Step 3 Title

Insurance / Payment Details

Do you have insurance? *
How will you be paying? *

Step 4 Title

PRE-EXISTING CONDITIONS

I have following condition(s): *
I have a condition that weakens my immune system or makes it harder to fight infections: *
I am taking one of these medications: *
Yes, I live, work or have visited a place where COVID-19 is widespread. *
Have you possibly been exposed to the Coronavirus in the past 2 weeks? *
Yes, I have been in close proximity (within 6 ft.) to someone who has been diagnosed with or presumed to have COVID-19. *
Do you have Diabetes Mellitus?
Are you suffering from Cardiovascular disease?
Are you suffering from Chronic Renal disease?
Are you suffering from Chronic Liver disease?
If female,are you currently pregnant?
Do have Immuno disorder?
Are you suffering from Neurological disability?
Are you suffering from Intellectual disability?
Do you have Other chronic diseases?
Do you have any Chronic Lung disease(asthma/emphysema/COPD)?
Yes
Other,specify

Step 6 Title

Have you had any of the following symptoms since December 2019: *
Are you currently experiencing any of these symptoms? *
ABSENT (No symptoms) - 0
Mild (Present, but minimal) - 1
MODERATE(tolerable) - 2
Severe - 3

Symptoms

Nasal discharge(runny nose)
Sneezing
Sinus pressure
Sinus pain
Wheezing
Shortness of breath(Dyspnea)
Frequent colds or sore throat
Cough
Headache
Fever/Chills
Diarrhea
Nausea or vomiting
Loss of smell or taste
Feeling tired,fatigue
Expectoration (Phalegm or Mucous)

PRE-EXISTING CONDITIONS1

Do You Have Any Pre-Existing Conditions?

EXPOSURE

In the last 14 days, have you come into contact with a person(s) known to be infected with COVID-19? *

Step 7 Title

Do You Have Allergies?
Do you smoke or use tobacco products?
I regularly use tobacco or nicotine products (e.g. cigarettes, e-cigarettes, vapes, hookah, etc.)
List any animals you are around on a regular basis.
Did the patient have another diagnosis/etiology for their illness?
If yes, what diagnosis?
Does the patient have an abnormal chest X-ray?
Does the patient have acute respiratory distress syndrome?

ASTHMA/ALLERGY MEDICATIONS

Antihistamines

0

1

2

3

Eye drops
Ointments
Nasal steroids(Flonase, Nasacort)
Oral steroids
Asthma medication(Inhaler, Singulair, Advair)
Other allergy medications?

EXPOSURE

Travel to a non-US country with a lab-confirmed SARS-CoV-2 (COVID-19) patient?
If yes, was this person a U.S. case?

Step 6 Title

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