Raw Score for this Application: out of - %

Q1. Last Name:

Q2. First Name:

Q3. Please enter the following: Email
Email:

Q4. 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.

Yes, I Agree for R.E.A.L to use my Information
No, I do not agree

Q5. Phone Number:

Q6. Age:

Q7. Date of Birth MM/DD/YYYY:

Q8. Gender:
Female:
Male:
Prefer not to say:

Q9. Do you have Health Insurance? Health Insurance IS NOT required, but if you have coverage we need to know.
Yes
No

Q10. If you answered "YES" above, please list: Health Insurance Company, Address, Policy Number, Phone Number:

Q11. Ethnicity
Black
White
Hispanic
Asian
Other

Q12. When did your symptoms begin MM/DD/YYYY?

Q13. Symptoms (check all that apply):
Cough
Shortness of Breath
Sneezing
Fever
Loss of Smell
Loss of Taste
Diarrhea
Tiredness or Fatigued
Sore Throat
None

Q14. Other Symptoms / More information about Symptons

Q15. Have you been around someone who tested positive for coronavirus or thought to be positive?
Yes
No

Q16. If you answered "yes" above, who was the person (family member, co-worker, etc.)

Q17. Do you have other medical problems?
HTN
DM
Cancer
Kidney Disease
Auto Immune Disease
None

Q18. Any other other Medical Problems / More Information on Medical Problems:

Q19. 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.

Yes
No