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509 Viking Drive Suite E, Virginia Beach, VA 23452

Doctor Using Digital Tablet

Patient COVID-19 eRegistration

Please fill out the following eRegistration Form prior to your scheduled appointment time.

SPECIAL INSTRUCTIONS REGARDING MINORS:

Minors under 15: Parent or legal guardian needs to fill out form and accompany patient to visit.
Age 16-17: Parent or legal guardian needs to fill out form.

*Please fill out Date of Birth

Have you experienced any of these symptoms? (select all that appply)
Do you have any of the following medical conditions? (select all that apply)
Are you currently pregnant? (Optional)
In the past 14 days, have you had known or suspected exposure to the SARS-CoV-2 virus or a COVID-19 patient?(e.g. been exposed to someone with COVID-19 or been in a large public gathering where exposure is suspected)
Are you a resident in a special setting where the risk of COVID-19 transmission may be high?(This may include long-term care, correctional and detention facilities; homeless shelters; assisted-living facilities and group homes.)
Are you taking this test for upcoming travel plans?

*We recommend a PCR Test for International Travel.

Do you work in health care?
Do you work in a special setting where the risk of COVID-19 transmission may be high? (This may include long-term care, correctional and detention facilities; homeless shelters; assisted-living facilities and group homes.)
Have you been prioritized for testing by a medical professional?
Is this your first time taking the COVID-19 test?
Have you previously tested positive for COVID-19?
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