***WE ONLY TEST PATIENTS SHOWING SYMPTOMS***

Personal Details

1/7

Address

2/7

Insurance

From the back of your insurance card, please enter the following information:
3/7

Symptoms

Cough?

Note: If you're experiencing shortness of breath, please count your breaths per minute. If this number is more than 25, please go to the emergency room immediately!

Shortness of Breath?

4/7

Symptoms

Fever

5/7

Risk Analysis

Please answer these questions to help evaluate your risk level

6/7

Health Issues

7/7
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Drive Thru Coronavirus Testing

By Dr. Stephen Sims of Cogent Family Healthcare in Mountain View.
cogent family healthcare
***WE ONLY TEST PATIENTS SHOWING SYMPTOMS***

Personal Details

1/7

Address

2/7

Insurance

From the back of your insurance card, please enter the following information:
3/7

Symptoms

Cough?

Note: If you're experiencing shortness of breath, please count your breaths per minute. If this number is more than 25, please go to the emergency room immediately!

Shortness of Breath?

4/7

Symptoms

Fever

5/7

Risk Analysis

Please answer these questions to help evaluate your risk level

6/7

Health Issues

7/7
Thanks! I have received your form submission, I'll get back to you shortly!
Oops! Something went wrong while submitting the form