COVID-19 At-Home Test Kit Survey
Please describe the option that best describes your symptoms:
If you have both severe and mild symptoms, select severe.
Severe
Select

I have a fever of 102° F or higher, OR I have a fever that has lasted longer than 48 hours.

I can’t speak in full sentences or do simple activities without feeling short of breath.

I am having severe coughing spells, or I am coughing up blood.

My lips or face are blue.

I have severe and constant pain or pressure in my chest.

I feel very tired or lethargic.

I feel dizzy, lightheaded, or too weak to stand.

I am having slurred speech or seizures.

I do not feel like I can stay at home because I feel seriously ill.

Mild
Select

I have a fever between 100.4° F and 102° F, am feeling feverish, or feel warm to the touch.

I have a new or worsening cough.

I have a new or worsening sore throat.

I am having flu-like symptoms (chills, runny or stuffy nose, headache, body aches, and/or feeling tired).

I am having shortness of breath that is not limiting my ability to speak.

I have new loss of taste or smell.

I have new nausea or vomiting.

I have new diarrhea.

None
Select

I am not having any symptoms or I am having symptoms not listed in the other two choices.

Have you been exposed to the coronavirus in the past 2 weeks?
Please select the option that most closely describes your level of exposure
Testing Recommended
Select

I've been asked to get testing by my healthcare provider, public health department, or a contact investigator.

Exposed or Sick Contact
Select

Yes, I have been in close proximity* to someone who has been diagnosed with or presumed to have COVID-19

*within 6 ft. of the person for a prolonged period of time or being coughed on

Congregate Setting
Select

Yes, I live or work in a place where people reside, meet, or gather in close proximity.*

*Includes nursing homes or other long term care facilities, healthcare settings, office buildings, workplaces, schools, group homes, homeless shelters, prisons, and detention centers.

Possible Exposure
Select
Do any of the following statements apply to you?
Please select the first option if ANY of these apply to you:
High Risk
Select

I am 65 years of age or older

I have been told by my doctor that I am very overweight or obese

I have a chronic condition (e.g. diabetes, high blood pressure, kidney disease or on dialysis, liver disease, lung disease, etc.)

I have a heart condition (e.g. previous heart attacks, heart failure, etc.)

I have a neurological condition that affects my ability to cough (e.g. had a stroke)

I am pregnant

I regularly use tobacco or nicotine products (e.g. cigarettes, e-cigarettes, vapes, hookah, etc.)

I have a condition that weakens my immune system or makes it harder to fight infections (e.g. AIDS, cancer, lupus, rheumatoid arthritis, solid organ or bone marrow transplant, etc.)

I am taking medication that weakens my immune system (e.g. steroids).

Low Risk
Select

None of these apply to me.

Choose a payment option to continue:
Insurance
Select

I would like to use my insurance

CARES Act
Select

I am not insured but I want to get free testing via CARES Act

Credit Card
Select

I would like to pay by credit card

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Shipping Address (We'll send your kit here)
Please fill out the information below
Shipping Address (We'll send your kit here)
Insurance Information

Your insurance denied your request.

BUT WAIT...

You can still get free testing from the CARES Act

CARES Act
Select

I am not insured but I want to get free testing via CARES Act

Credit Card
Select

I would like to pay by credit card