COVID-19 Test (At-Home Collection Kit) - Questionnaire

COVID-19 Payment

Please select the option that is right for you.

Kits are available for $0 upfront cost for individuals with insurance who complete a short survey and meet clinical testing guidelines. For those who are uninsured, do not wish to take the survey, or do not meet clinical testing guidelines, kits are available for purchase.

$0 Upfront Cost With Insurance*

This option is intended for those who:

Are experiencing symptoms
Have been exposed to someone with COVID-19
Live or work in a congregate setting
Have been asked to get tested by a healthcare professional, contact investigator, or public health department

I would like to take the survey to see if I am eligible for $0 upfront cost to bill my insurance.

Pay $119.00*

This option is intended for:

Uninsured and need COVID-19 testing
Testing for school/workplace screening, travel, events, or peace of mind
Purchasing up to 5 kits at once

I would like to skip the survey and purchase the test out of pocket.

*If you feel like you are having a medical emergency, please call 9-1-1. If you are experiencing severe trouble breathing; continuous pain or pressure in your chest; feeling confused; or having diﬃculty waking up or staying awake; pale, gray, or blue-colored skin, lips, or nail beds; or any other emergency signs or symptoms, please seek immediate medical care.

COVID-19 Symptoms

Please describe the option that best describes your symptoms:

If you have both severe and mild symptoms, select severe.

Severe

I have a fever of 102° F or higher, OR I have a fever that has lasted longer than 48 hours.
I can’t speak in full sentences or do simple activities without feeling short of breath.
I am having severe coughing spells, or I am coughing up blood.
My skin or lips or nail beds are blue.
I have severe and constant pain or pressure in my chest.
I feel very tired or lethargic.
I feel dizzy, lightheaded, or too weak to stand.
I am having slurred speech or seizures.
I do not feel like I can stay at home because I feel seriously ill.

Mild

I have a fever between 100.4° F and 102° F, am feeling feverish, or feel warm to the touch.
I have a new or worsening cough.
I have a new or worsening sore throat.
I am having flu-like symptoms (chills, runny or stuffy nose, headache, body aches, and/or feeling tired).
I am having shortness of breath that is not limiting my ability to speak.
I have new loss of taste or smell.
I have new nausea or vomiting.
I have new diarrhea.

None

I am not having any symptoms or I am having symptoms not listed in the other two choices.

COVID-19 Exposure

Have you been exposed to the coronavirus in the past 2 weeks?

Please select the option that most closely describes your level of exposure:

Testing Recommended

I've been asked to get testing by my healthcare provider, public health department, or a contact investigator.

Exposed or Sick Contact

Yes, I have been in close proximity* to someone who has been diagnosed with or presumed to have COVID-19

*within 6 ft. of the person for a prolonged period of time or being coughed on

Congregate Setting

Yes, I live or work in a place where people reside, meet, or gather in close proximity.*

*Includes nursing homes or other long term care facilities, healthcare settings, office buildings, workplaces, schools, group homes, homeless shelters, prisons, and detention centers.

Unexposed

No, I have not been exposed.

If you are a healthcare professional, first responder, frontline worker, or critical infrastructure worker and believe you have been directly exposed while at work, you should consult your place of work for specific occupational health guidance about whether to stay home or continue working. You should adhere to recommendations set forth by your employer or the department of health, as they may differ from the CDC's guidelines.

COVID-19 Risk

Do any of the following statements apply to you?

Please select the first option if ANY of these apply to you:

High Risk

I am 65 years of age or older
I have been told by my doctor that I am very overweight or obese
I have a chronic condition (e.g. diabetes, high blood pressure, kidney disease or on dialysis, liver disease, lung disease, etc.)
I have a heart condition (e.g. previous heart attacks, heart failure, etc.)
I have a neurological condition that affects my ability to cough (e.g. had a stroke)
I am pregnant
I regularly use tobacco or nicotine products (e.g. cigarettes, e-cigarettes, vapes, hookah, etc.)
I have a condition that weakens my immune system or makes it harder to fight infections (e.g. AIDS, cancer, lupus, rheumatoid arthritis, solid organ or bone marrow transplant, etc.)
I am taking medication that weakens my immune system (e.g. steroids, chemotherapy, immunologics, etc.)

Low Risk

None of these apply to me.

Leave this field blank (Optional)

COVID-19 At-Home Test Kit Survey