Coronavirus Form

If you need immediate medical assistance please dial 911. If you are showing symptoms of Coronavirus please contact a local medical provider if you have not already done so. Any and all health information entered is done so voluntarily for the purpose of contact tracing. By submitting this form you are agreeing that all HIPPA rights are being waived in favor of the safety of the community. This form does not guarantee a medical professional will reach out to you.

Are you reporting for yourself? *

What is their zip code? *

What is their address? *

Is the person alive? *

Are they showing signs/symptoms for Coronavirus? *

Describe their symptoms? *

Have they been tested? *

Did they test positive? *

Why are you contacting us? *

Enter your zip code: *

Are you showing signs/symptoms for Coronavirus? *

Do you want to be tested? *

Describe your symptoms? *

Have you been tested? *

Did you test positive? *

Age *

Gender *

Ethnicity *

Please share with us where you have been, and how you think you contracted it. Be as specific as you feel comfortable. (Address, dates, times, etc.) *

Date / Time

Date

Time

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Why are you contacting us? *

Do you have other health concerns? *

Yes
No

Location *

Estimated #of people present *

Type of event *

Do you need help seeking treatment? *

Enter your email address *