Raw Score for this Application: 76 out of 34 - 223.52941176471%
Q1. Please enter the following: First Name, Last Name Gayle LinK
Q2. Please enter the following: Email Email:
Q3. R.E.A.L. will protect your information. Information is only used as is reasonably necessary to process your application or to provide you with health or counseling services which may require communication between HHSN and health care providers, medical product or service providers, pharmacies, insurance companies, and other providers necessary to verify your medical information is accurate and determine the type of medical supplies or health care services you need.
Q4. Phone Number: 4045438300
Q5. Age: 21
Q6. Date of Birth MM/DD/YYYY: 03/13/1990
Q7. Gender:
Q8. Do you have Health Insurance? Health Insurance IS NOT required, but if you have coverage we need to know.
Q9. If you answered "YES" above, please list: Health Insurance Company, Address, Policy Number, Phone Number: University Stuff
Q10. Ethnicity
Q11. When did your symptoms begin MM/DD/YYYY? 10/02/1700
Q12. Symptoms (check all that apply):
Q13. Other Symptoms / More information about Symptons Input
Q14. Have you been around someone who tested positive for coronavirus or thought to be positive?
Q15. If you answered "yes" above, who was the person (family member, co-worker, etc.) Input
Q16. Do you have other medical problems?
Q17. Any other other Medical Problems / More Information on Medical Problems: Input - yep
Q18. DISCLAIMER: You agree and affirm that you will not hold REAL Concierge Medicine or Black Doctors COVID19 Consortium liable for any issues associated with your testing and or test results and subsequent treatment or care you receive from another facility or ambulance.