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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

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

How did you hear about Fastpace?

Do you have any COVID-19 symptoms?

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

Select Employer or Organization Name

Employer Phone

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

How would you like to pay for your visit?

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?