Leaders in Healthcare

COVID-19 Testing Request

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COVID-19 Testing Request

This service is being offered to patients of Coastal Medical with symptoms of COVID-19. If you are not a current Coastal Medical patient, and require testing or evaluation, please visit portal.ri.gov for information and assistance.

For current Coastal patients who are experiencing signs and/or symptoms of COVID-19, and would like to schedule a test, please complete the form below. Thank you!

Are you a current patient of Coastal Medical? *

Yes

If you are not a Coastal Medical patient, please visit portal.ri.gov for additional information and assistance.

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Email Address

Patient's Cell Phone Number

Can we text you at this number?

Yes

Patient's Insurance Provider

Patient's Insurance Number

Are you currently experiencing signs and/or symptoms of COVID-19?

Yes

If you do NOT have COVID-19 symptoms, please visit portal.ri.gov for additional information and assistance.

Symptoms *

Please check all of the symptoms you are currently experiencing.

Fever or chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

Symptom Onset *

When did you first begin feeling sick?

Other risk factors

I have a chronic illness

I have conditions which weaken my immune system

I am a school-aged student or K-12 staff member

Recent close contact with a person who has tested positive for COVID-19 (A close contact is someone you have been within 6 feet of for 15 minutes or more starting two days before they got tested or started having symptoms of COVID-19)

Recent travel - domestic or international

Recent mass gathering (more than 100 people)

No other risk factors

Preferred Location of Testing

Preferred Time of Testing

Thank you for submitting this information. You will receive a confirmation by text typically within 24 hours of this request.