Wireframe

Intake Form

Personal Information:
First name:
Last name:
Date of birth (MM/DD/YYYY):
Phone number:
Male Female

Medical Information:

Have you experienced any of the following symptoms in the last two weeks?

Runny nose
Cough
Headaches
Blurry vision
Sore muscles
Excessive thirst

Please describe any additional symptoms:

What is your primary reason for requesting an appointment?

Passcode sent to your email verifying your identity: