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Testing Registration Form
First Name
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Middle Initial:
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Last Name
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Social Security:
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Date of Birth:
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Mobile Number
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E-Mail
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Address
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City
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State
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Zip
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Gender
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Ethnicity
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Race
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Choose Your Location
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  • Crump
  • Rossville
  • Outreach Event
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Have you had a fever?
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Have shaking chills?
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Have you had any difficulty breathing or shortness of breath?
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Acute onset of sore throat without other cause?
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Have you been coughing?
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Acute onset of myalgia (muscle aches or pain) without other cause?
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Do you have any chest discomfort, such as pressure or fullness?
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Acute onset loss of smell and taste without other cause?
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Have you had close contact with an individual who has tested positive for Covid-19 within the last 14 days?
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Healthcare worker with any respiratory symptoms following close contact with suspected (unconfirmed) COVID-19 case.
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Are you a healthcare worker?
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  • Yes
  • No
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Who is your primary care provider (choose from the drop down list)
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  • 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
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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.
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Insurance policy ID
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Insurance Group #
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Insurance Subscriber number
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