Get TestedTesting Registration FormField is required!Field is required!First NameYour First NameField is required!Field is required!Middle Initial:Your Middle InitialField is required!Field is required!Last NameYour Last NameField is required!Field is required!Social Security:Your Social Security #Field is required!Field is required!Date of Birth:mm/dd/yyyyField is required!Field is required!Mobile NumberYour Phone NumberField is required!Field is required!E-Mailname@example.comField is required!Field is required!AddressYour AddressField is required!Field is required!CityCityField is required!Field is required!State- select a state -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonMarylandMassachusettsMichiganMinnesotaMississippiMissouriPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming- select a state -Field is required!Field is required!ZipZipcodeField is required!Field is required!Gender- select a option -MaleFemaleOther- select a option -Please make a selection.Please make a selection.Ethnicity- select a option -HispanicNon-HispanicOther- select a option -Please make a selection.Please make a selection.Race- select a option -Black or African American WhiteAsianHispanic or LatinoAmerican Indian or Alaska NativeOther- select a option -Please make a selection.Please make a selection.Choose Your Location- select a option -CrumpRossvilleOutreach Event- select a option -Field is required!Field is required!Have you had a fever?YesNoPlease make a selection.Please make a selection.Have shaking chills?YesNoPlease make a selection.Please make a selection.Have you had any difficulty breathing or shortness of breath?YesNoPlease make a selection.Please make a selection.Acute onset of sore throat without other cause?YesNoPlease make a selection.Please make a selection.Have you been coughing?YesNoPlease make a selection.Please make a selection.Acute onset of myalgia (muscle aches or pain) without other cause?YesNoPlease make a selection.Please make a selection.Do you have any chest discomfort, such as pressure or fullness?YesNoPlease make a selection.Please make a selection.Acute onset loss of smell and taste without other cause?YesNoPlease 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?YesNoPlease make a selection.Please make a selection.Healthcare worker with any respiratory symptoms following close contact with suspected (unconfirmed) COVID-19 case.YesNoPlease make a selection.Please make a selection.Are you a healthcare worker?- select a option -YesNo- 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 SystemsChrist Community Health ServicesChurch Health CenterMemphis Health CenterTri-State Community Health CenterOther not listed aboveI 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 InfoField is required!Field is required!Insurance policy IDEnter InfoField is required!Field is required!Insurance Group #Enter InfoField is required!Field is required!Insurance Subscriber numberEnter InfoField is required!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.Please make selection.Please make selection.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.Please make selection.Please make selection.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.Please make selection.Please make selection.Submit
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