Help Scheduling An Appointment – The COVID-19 Long Haul Foundation

Patient Full Name *

Date of Birth *

Gender *

Email *

Telephone Contact *

Cell Tellephone *

Street Address

City

State

Zip

Medical Problem Associated with Your Long-haul Condition

Second Medical Problem Associated with Your Long-haul Condition (copy)

Please List All Other Long-haul Medical Problems You Are Experiencing

When Did Your Medical Conditions Begin? Are your problems getting worse?

Have you been treated for Long-COVID?

Have you been hospitalized for Long-COVID?

How Far Can You Travel for Your Appointment

Do You Have Medical Insurance?

Preferred Appointment Date *

The preferred date may vary upon the doctor’s availability.

Do You Agree to Allow Us to Contact A Long-haul Expert to Schedule Your Visit?

Preferred Time *

We are available between 6:00 AM to 10:30 PM.