Get Tested

Testing Registration Form
First Name
Your First Name
Field is required!
Field is required!
Middle Initial:
Your Middle Initial
Field is required!
Field is required!
Last Name
Your Last Name
Field is required!
Field is required!
Social Security:
Your Social Security #
Field is required!
Field is required!
Date of Birth:
mm/dd/yyyy
Field is required!
Field is required!
Mobile Number
Your Phone Number
Field is required!
Field is required!
E-Mail
name@example.com
Field is required!
Field is required!
Address
Your Address
Field is required!
Field is required!
City
City
Field is required!
Field is required!
State
  • - select a state -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
- select a state -
Field is required!
Field is required!
Zip
Zipcode
Field is required!
Field is required!
Gender
  • - select a option -
  • Male
  • Female
  • Other
- select a option -
Please make a selection.
Please make a selection.
Ethnicity
  • - select a option -
  • Hispanic
  • Non-Hispanic
  • Other
- select a option -
Please make a selection.
Please make a selection.
Race
  • - select a option -
  • Black or African American
  • White
  • Asian
  • Hispanic or Latino
  • American Indian or Alaska Native
  • Other
- select a option -
Please make a selection.
Please make a selection.
Choose Your Location
  • - select a option -
  • Crump
  • Rossville
  • Outreach Event
- select a option -
Field is required!
Field is required!
Have you had a fever?
Please make a selection.
Please make a selection.
Have shaking chills?
Please make a selection.
Please make a selection.
Have you had any difficulty breathing or shortness of breath?
Please make a selection.
Please make a selection.
Acute onset of sore throat without other cause?
Please make a selection.
Please make a selection.
Have you been coughing?
Please make a selection.
Please make a selection.
Acute onset of myalgia (muscle aches or pain) without other cause?
Please make a selection.
Please make a selection.
Do you have any chest discomfort, such as pressure or fullness?
Please make a selection.
Please make a selection.
Acute onset loss of smell and taste without other cause?
Please make a selection.
Please make a selection.
Have you had close contact with an individual who has tested positive for Covid-19 within the last 14 days?
Please make a selection.
Please make a selection.
Healthcare worker with any respiratory symptoms following close contact with suspected (unconfirmed) COVID-19 case.
Please make a selection.
Please make a selection.
Are you a healthcare worker?
  • - select a option -
  • Yes
  • No
- select a option -
Field is required!
Field is required!
Who is your primary care provider (choose from the drop down list)
  • - select a option -
  • Cherokee Health Systems
  • Christ Community Health Services
  • Church Health Center
  • Memphis Health Center
  • Tri-State Community Health Center
  • Other not listed above
  • I don't have a primary care provider
- select a option -
Field is required!
Field is required!
There is no out of pocket cost for COVID-19 testing; however, we are required to obtain insurance information from you. Please provide your Insurance subscriber/guarantor name and DOB.
Enter Info
Field is required!
Field is required!
Insurance policy ID
Enter Info
Field is required!
Field is required!
Insurance Group #
Enter Info
Field is required!
Field is required!
Insurance Subscriber number
Enter Info
Field is required!
Field is required!
Please make selection.
Please make selection.
Please make selection.
Please make selection.
Please make selection.
Please make selection.