Mako Medical

Location: International Focus

1630 Crescent Place, NW, Washington DC 20009, US

Thursday, Apr 6th, 2023; 9am-10am; 12 people; Hampton Inn & Suites, Raleigh – by Crabtree Valley, 3920 Arrow Drive, Raleigh, NC 27612

Patient Information

First Name

Middle Initial

Last Name

DOB

Sex

Race

Ethnicity

Phone Number

Social Security Number

Driver License/ID Number

U.S. Address

Address 2

City

State

Zip

Payment Options

Free community test I have insurance

Insurance

Insurance not listed

Policy Number

Group Number

Custom State Required Questions

1. First Test?

Yes No Unknown

2. Employed in healthcare?

Yes No Unknown

3. Hospitalized?

Yes No Unknown

4. ICU?

Yes No Unknown

5. Resident in a congregate care setting (including nursing homes, residential care for people with intellectual and developmental disabilities, psychiatric treatment facilities, group homes, board and care homes, homeless shelter, foster care or other setting):

Yes No Unknown

6. Pregnant?

Yes No N/A

7. Symptomatic as defined by CDC?

According to the CDC:
People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

Yes No Unknown

Date of Symptom Onset:

Register for Testing

Location: International Focus

1630 Crescent Place, NW, Washington DC 20009, US

Patient Information

Payment Options

Custom State Required Questions