Dr. Stephen J. Sims |
Schedule COVID-19 Test
Drive Thru Coronavirus Testing
By Dr. Stephen Sims of Cogent Family Healthcare in Mountain View.
***WE ONLY TEST PATIENTS SHOWING SYMPTOMS***
Date of Birth
Plan Type (PPO, HMO etc.)
Name of Insured
Date of Birth of Insured
Policy ID Number
From the back of your insurance card, please enter the following information:
Company name to mail claims to
P.O. Box Number
How many days?
Cough type (check all that apply)
Shortness of breath (feeling like you just ran, but you didn't)
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!
Is your cough getting better or worse?
Do you have a sore throat?
Fever in the past 2 days?
If yes, what was your highest temperature?
Other Symptoms (check all that apply)
Onset within the first day, of severe fatigue
New yellow, green, or bitter cloudy nose mucus
Significant muscle aches in thighs, arms, or back
New significant loss of smell or taste
Much lower amount of urine than usual
Please answer these questions to help evaluate your risk level
Have you been in contact, within 6 feet, for more than 15min, with a COVID positive patient?
Are you taking immunosuppressive medications?
Are you a healthcare worker or first responder?
Are you in a third trimester pregnancy?
Are you living in a board and care facility?
Please check any disease(s) you currently have or have suffered from in the past.
Lung Disease - from smoking
Other Lung Disease
High Blood Pressure
None listed above
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