KC Wellness Center Covid-19 Testing Form

Please fill out the form below. You will asked to sign this form, medical forms release and our confidentiality agreement upon your first visit.

NOTE: Your health information will be kept strictly confidential. Any information that we collect about you on this form will be kept confidential in our offices.

Thanks!

Covid-19 Testing Form

Name*
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Date Of Birth*
Please check any of the following symptoms you have experienced in the past 14 days*
- Fever
- Shortness of breath
- Diarrhea
- Cough
- Post nasal drip
- Body ache
- Headache
- Other
- None
Comments
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Phone
This field is for validation purposes and should be left unchanged.