Consent Form | COVID-19 Testing

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To save a little time please fill out this form and bring it with you. If not, be prepared to fill out this form when you arrive for testing.

Test: (Check all Apply)

PCR Swab Test

IgG/IgM

Influenza PCR

Have you experienced any of the following symptoms? (Patient circle)

Fever

Dry Cough

Shortness of breath

Difficulty breathing

Diarrhea

Loss of Appetite

Recent Travel

Tiredness

Body Ache

Nasal Congestion

Runny Nose

Loss of Smell/Taste

None

Does the patient have any underlying conditions? (Patient circle)

None

Unknown

Cardiac Disease

Pregnant

Chronic Liver Disease

Diabetes

Hypertension

Immunocompromised

Chronic Kidney Disease

Choice 1

Thanks for submitting!

Quick Links

Contact Info

909-600-8635

Rancho Cucamonga, Ca

714-941-9076

Orange, Ca

310-997-7468

Torrance/Los Angeles

County

Locations

9785 Magnolia Avenue

Riverside, Ca 92503

9591 Foothill Boulevard

Rancho Cucamonga,

Ca 91730

830 N Tustin Ave Orange, CA

92867

1730 Sepulveda Blvd Ste 2

Torrance Ca, 90501