COVID-19 PCR, Antigen and Antibody Test Questionnaire

Your full name?*

Your date of birth?*

Email*

Have you experienced fever higher than 100.5º F in the last 3 days?*

In the last 10 days, have you experienced loss of smell or taste?

In the last 10 days, have you experienced shortness of breath or difficulty breathing?*

In the last 10 days, have you experienced feeling weak or lethargic?*

In the last 10 days, have you experienced lightheadedness or dizziness?*

In the last 10 days, have you experienced vomiting or diarrhea?*

In the last 10 days, have you experienced slurred speech?*

In the last 10 days, have you experienced seizures?*

Have you been tested for and diagnosed with COVID-19 infection?*

Have you been exposed to anyone with known COVID-19 infection in the last 14 days?*

If approved, you will receive a link to purchase the COVID-19 antibody test.

BioCentra LLC, 3000 Joe DiMaggio Blvd Ste 77, Round Rock, TX 78665, US