COVID-19 Response Web App

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What is the date you started showing symptoms?
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Your Information

First Name
Last Name
Street Address
Zip Code
Date of birth
Phone
Do you have Driver’s License?

Are You Insured? ?

Email
Emergency/Guardian Contact Name
Emergency/Guardian Contact Email
Emergency/Guardian Contact Relationship
Emergency/Guardian Contact Phone
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Alert!

Please call 911 or go to the ER immediately as your symptoms require a Doctor's care and you cannot wait for a test to be scheduled

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