* must provide value
Please select your preferred language: English
Por favor seleccione su idioma preferido: Español
Please select your preferred language: English
Por favor seleccione su idioma preferido: Español
By marking "Yes" in this box and completing the registration form, I am consenting to COVID-19 testing. This test will be administered by Heart to Heart International. I acknowledge the results of this test and my information will be shared with state and local public health officials in compliance with reporting laws.* must provide value
Yes
Where are you planning to be tested?* must provide value
Claycomo Community Building - 28 S. Drake, Kansas City, MO American Legion Post 58 - 2607 State Route 92, Smithville, MO Kansas City North Community Center - 3930 NE Antioch Rd, Kansas City, MO Northland Cathedral - 101 NW 99th St, Kansas City, MO Tower View Baptist Church - 7301 NE 50th St, Kansas City, MO Smithville Senior Center - 113 W. Main St, Smithville, MO
Which date would you like to be tested?
Which date would you like to be tested?
Which date would you like to be tested?
Which date would you like to be tested?
Which date would you like to be tested?
Which date would you like to be tested? 12/10/2020
Which date would you like to be tested?
Which date would you like to be tested?
Which date would you like to be tested?
Which date would you like to be tested? 12/14/2020
Which date would you like to be tested?
Which date would you like to be tested? 12/16/2020
Which date would you like to be tested?
Which date would you like to be tested?
Which date would you like to be tested?
Which date would you like to be tested?
Which date would you like to be tested? 12/15/2020
Which date would you like to be tested?
Which date would you like to be tested?
Which date would you like to be tested? 12/9/2020
Which date would you like to be tested?
Which date would you like to be tested? 12/29/2020
Which date would you like to be tested? 2/25/2021 3/4/2021 3/11/2021 3/18/2021 3/25/2021
Which date would you like to be tested? 3/9/2021 3/16/2021 3/23/2021 3/30/2021
Which date would you like to be tested? 2/18/2021 3/2/2021
Which date would you like to be tested? 2/23/2021
Which date would you like to be tested? 2/24/2021 3/3/2021 3/10/2021 3/17/2021 3/24/2021 3/31/2021
Which date would you like to be tested? 2/22/2021 3/1/2021 3/8/2021 3/15/2021 3/22/2021 3/29/2021
First Name:* must provide value
Last Name:* must provide value
We need you to complete the data below to register you to receive a COVID-19 test. This information is required for us to be able to contact you with your test results and ensure we are communicating with the correct person. Necesitamos que complete los datos a continuación para poder registrarse y recibir una prueba COVID-19. Esta información es necesaria para que podamos comunicarnos con usted con los resultados de su prueba y asegurarnos de que nos estamos comunicando con la persona correcta. Today's Date:* must provide value
Now M-D-Y H:M
What is your date of birth?* must provide value
M-D-Y
Please enter the best phone number to reach you at with your test results:* must provide value
Please enter the best email to reach you:
If we are unable to reach you, can we leave test results on your voicemail or email?* must provide value
Yes, voicemail / Si, correo de voz
Yes, email / Si, correo electrónico
No / No
Yes, voicemail / Si, correo de voz
Yes, email / Si, correo electrónico
No / No
Street Address:* must provide value
Apt # or line 2 of your address:
City:* must provide value
State:* must provide value
Missouri
Kansas
Other
What other state:
Please enter your Zip Code:* must provide value
What county do you live in?* must provide value
Clay County
Jackson County
Platte County
Cass County
Other Missouri county
Clay County
Jackson County
Platte County
Cass County
Other Missouri county
What county do you live in?* must provide value
Wyandotte County
Johnson County
Douglas County
Leavenworth County
Other Kansas county
Wyandotte County
Johnson County
Douglas County
Leavenworth County
Other Kansas county
If you are employed, where is your employer located?* must provide value
Missouri
Kansas
Other
I'm unemployed or retired
Missouri
Kansas
Other
I'm unemployed or retired
Employer county?* must provide value
Wyandotte County
Johnson County
Douglas County
Leavenworth County
Other Kansas county
Wyandotte County
Johnson County
Douglas County
Leavenworth County
Other Kansas county
Employer county?* must provide value
Clay County
Jackson County
Platte County
Cass County
Other Missouri county
Clay County
Jackson County
Platte County
Cass County
Other Missouri county
Please specify your gender:* must provide value
Male/Masculino
Female/Femenino
Other/Otro
Male/Masculino
Female/Femenino
Other/Otro
Other gender (define):
Current Age: View equation
What is your race (check all that apply)? African American/Black
Asian
Native American/Alaska Native
Native Hawaiian/Pacific Islander
White
Other
African American/Black
Asian
Native American/Alaska Native
Native Hawaiian/Pacific Islander
White
Other
¿Cuál es su raza (marque todo lo que corresponda)? Afroamericano / Negro
Asiático
Nativo Americanos / Nativo de Alaska
Nativo de Hawái / Isleño del Pacífico
Blanco
Otro
Afroamericano / Negro
Asiático
Nativo Americanos / Nativo de Alaska
Nativo de Hawái / Isleño del Pacífico
Blanco
Otro
Are you of Hispanic or Latino descent? (Mexican, Mexican American, Chicano, Puerto Rican, Cuban, South or Central American or other Spanish culture or origin) Yes
No
¿Es usted de ascendencia hispana o latina? (mexicano, mexico-americano, chicano, puertorriqueño, cubano, sudamericano o centroamericano o de otra cultura/ origen español) Si
No
Have you ever been tested for COVID-19?* must provide value
Yes, had a positive test
Yes, had a negative test
No
I don't know
Yes, had a positive test
Yes, had a negative test
No
I don't know
¿Alguna vez le han hecho la prueba de COVID-19?* must provide value
Sí, tuve una prueba positiva
Sí, tuve una prueba negativa
No
No sé
Sí, tuve una prueba positiva
Sí, tuve una prueba negativa
No
No sé
The option "
During the PAST TWO WEEKS have you had any of the following symptoms? Cough
Fever (101 or greater)
Shortness of breath
Fatigue or feeling significantly tired from illness
Loss of sense of taste
Loss of sense of smell
Gastrointestinal symptoms (nausea, loss of appetite, diarrhea)
I don't have any symptoms
Cough
Fever (101 or greater)
Shortness of breath
Fatigue or feeling significantly tired from illness
Loss of sense of taste
Loss of sense of smell
Gastrointestinal symptoms (nausea, loss of appetite, diarrhea)
I don't have any symptoms
¿Durante las ÚLTIMAS DOS SEMANAS ha tenido alguno de los siguientes síntomas? Tos
Fiebre (101 o mayor)
Dificultad para respirar
Fatiga o sentirse significativamente cansado por una enfermedad.
Pérdida del sentido del gusto.
Pérdida del sentido del olfato.
Síntomas gastrointestinales (náuseas, pérdida de apetito, diarrea)
No tengo síntomas
Tos
Fiebre (101 o mayor)
Dificultad para respirar
Fatiga o sentirse significativamente cansado por una enfermedad.
Pérdida del sentido del gusto.
Pérdida del sentido del olfato.
Síntomas gastrointestinales (náuseas, pérdida de apetito, diarrea)
No tengo síntomas
Why are you being tested? Upcoming travel
Visiting with family/friends
High risk loved one
Exposure to someone who is positive
Experiencing symptoms
Required for work
Curious about status
Another reason
Upcoming travel
Visiting with family/friends
High risk loved one
Exposure to someone who is positive
Experiencing symptoms
Required for work
Curious about status
Another reason
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