Request Test Covid-19 First Name *Last Name *Gender *MaleFemaleAge *Date of Birth *Nationality *ID Number *Phone Number *Email Home Address *work: place/ position: *Please select the statement that apply to you *Diagnosed chronic diseases (eg. Diabetes, blood pressure, obesity) Diagnosed chronic lung disease History of heart failureCurrent cancer Diseases or Drugs that weaken immune systemHistory of chronic liver disease or Kidney diseaseNone of the above Do you have any of the following symptoms? *Fever CoughShortness of breath Fatigue Muscle pain ChillsDiarrheaNauseaSore throatNone of the above Date of Observation Are your symptoms rapidly worsening? *YesNoHave you had close contact with a person suspected of having COVID-19 in the past 14 days? *YesNoPlease select the statement that apply to you *I have lived with or have provided care to a person suspected of having COVID-19I have shared the same closed environment ( e.g Home, party, classroom, workplace, gym) with a person suspected of having COVID-19I have traveled inside or outside Saudi Arabia in the past 14 daysOther type of contact None of the above If you have done the COVID-19 Test in the past 14 days, the result was? *PositiveNegativesNone of the above; It is my first timeCommentSubmit
