Eldahmy Wellness Pharmacy is an official testing center for COVID-19.

Patient First Name

Patient Last Name

Patient Date of Birth

Email Address

Mailing Address

Phone Number

Do you need help getting your medications delivered?
YesNo

Which pharmacy do you currently use to pick up your medication ( include the branch)

Have you recently traveled to an area with known spread of COVID-19?
YesNo

Have you come into close contact (within 6 feet) with someone who has a laboratory confirmed COVID – 19 diagnosis in the past 14 days?
YesNo

Do you have a fever (greater than 100.4 F or 38.0 C) OR symptoms of lower respiratory illness such as cough, shortness of breath, difficulty breathing or sore throat?
YesNo

Please select which symptoms you are currently experiencing.
FeverDifficulty Breathing or Shortness of BreathCoughSore ThroatAll the above

Are you a first responder, healthcare worker, or employee or attendee of a child or adult care facility?
YesNo

Please Enter Three Available Dates for Testing

Any other questions or comments?