Covid Registry Form

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This is a great place to tell people more about yourself and peak their interest.

For more info, they can follow you on social in a click.

This is a great place to tell people more about yourself and peak their interest.

For more info, they can follow you on social in a click.

Use tab to navigate through the menu items.

Please enter your contact information

Not a valid Email address

For how many days were you hospitalized?

Are you a confirmed COVID-19 patient?

Yes

No

Enter Race

Were you hospitalized?

Yes

No

Enter Country

When were you diagnosed?

Enter Height in feet and inches

Underlying Conditions

Treatment Medicine

Have you used a ventilator?

Yes

No

How old are you?

Enter Weight in Ibs

Enter Gender

Check Symptoms that Apply

Fever

Trouble Breathing

Dry Cough

Loss of Taste

Loss of smell

Tiredness

Aches and Pains

Nasal Congestion

Runny Nose

Sore Throat

Other

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Would you be willing to be contacted if we need further clarification?

Yes

No

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