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Patient First Name

Patient Last Name

Visit Day

Visit Time

Cell Phone Number

New or Existing Patient

Date of Birth

Gender assigned at birth

Are you following-up with Fast Pace Health after testing positive for, or being diagnosed with, coronavirus (COVID-19)?

Have you recently traveled or been in close contact with someone suspect or confirmed to be positive for Coronavirus (COVID-19)?

Other Reason for Visit

How did you hear about Fastpace?

Do you have a fever, cough or shortness of breath?

Do you have any COVID-19 symptoms?

Have you been exposed to COVID-19 in the last 14 days?

Organization or Employer Name

Employer Phone

How would you like to pay for your visit?

Have you recently traveled or been in close contact with someone suspected or confirmed to be positive for Coronavirus (COVID-19)?

Would you like to receive a COVID Antibody Test to determine if you have had a past COVID infection?

Would you like to receive a COVID Viral Test to determine if you have a current COVID infection?

Would you like to receive Telemedicine services from your Smartphone or Tablet in the comfort of your home?

Would you like a Flu Vaccine today?

Would you like to receive text message marketing updates on First Care’s services and seasonal offerings?

Are you requesting a COVID-19 test?