Get Tested
Testing Registration Form
First Name
Your First Name
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Middle Initial:
Your Middle Initial
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Last Name
Your Last Name
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Social Security:
Your Social Security #
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Date of Birth:
mm/dd/yyyy
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Mobile Number
Your Phone Number
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E-Mail
name@example.com
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Address
Your Address
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City
City
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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
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Zip
Zipcode
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Gender
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Male
Female
Other
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Please make a selection.
Ethnicity
- select a option -
Hispanic
Non-Hispanic
Other
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Please make a selection.
Race
- select a option -
Black or African American 
White
Asian
Hispanic or Latino
American Indian or Alaska Native
Other
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Please make a selection.
Choose Your Location
- select a option -
Crump
Rossville
Outreach Event
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Have you had a fever?
Yes
No
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Please make a selection.
Have shaking chills?
Yes
No
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Please make a selection.
Have you had any difficulty breathing or shortness of breath?
Yes
No
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Please make a selection.
Acute onset of sore throat without other cause?
Yes
No
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Please make a selection.
Have you been coughing?
Yes
No
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Please make a selection.
Acute onset of myalgia (muscle aches or pain) without other cause?
Yes
No
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Please make a selection.
Do you have any chest discomfort, such as pressure or fullness?
Yes
No
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Please make a selection.
Acute onset loss of smell and taste without other cause?
Yes
No
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Please make a selection.
Have you had close contact with an individual who has tested positive for Covid-19 within the last 14 days?
Yes
No
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Please make a selection.
Healthcare worker with any respiratory symptoms following close contact with suspected (unconfirmed) COVID-19 case.
Yes
No
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Please make a selection.
Are you a healthcare worker?
- select a option -
Yes
No
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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
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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.
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Insurance policy ID
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Insurance Group #
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Insurance Subscriber number
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Field is required!
Check the box to indicate that you understand that you consent to be called, screened, assessed and tested for COVID19 by Memphis Health Center, Inc.
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Check the box to indicate that you understand that you consent for your medical information to be shared with other relevant medical community members assisting with COVID19 assessment and follow-up.
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By submitting this form, you agree to allow Memphis Health Center, Inc. to send you results through the patient portal using the email address you have provided above. Please contact us if you do not receive an email to register within 5 business days.
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