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Testing Registration Form
First Name
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Last Name
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Please briefly describe your symptoms
255 character limit
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Check the box if the Shelby County Health Department has called you to say you have been exposed to someone who has tested positive for COVID-19
Check the box if you have travelled outside of the mid-south area in the last 14 days
check the box if you HAVE had contact with someone in the last 14 days that has tested POSITIVE of COVID-19
Check if you have had a flu test in the last 7 days
Check if your recent flu test was positive
We are adding testing locations, please select the location best for you
Select Option
Any location as soon as possible
Third Street, Memphis (most days)
Frayser, Memphis (1 day a week)
Hickory Hill, Memphis (1 day a week)
Jackson, TN (1 day a week)
Broad Avenue, Memphis (1 day a week)
Orange Mound, Memphis (1 day a week)
Raleigh, Memphis (1 day a week)
Lamar Testing Site
Who is your primary care provider (choose from the drop down list)
Select Option
Cherokee Health Systems
Christ Community Health Services
Church Health Center
Memphis Health Center
TriState Community Health Center
Other not listed above
I don't have a primary care provider
There is no out of pocket cost for COVID19 testing; however, we are required to obtain insurance information from you. Please provide your insurance carrier name
Insurance policy ID
Insurance Group #
Insurance Subscriber number
Check the box to indicate that you understand that you consent to be called, screened, assessed and tested for COVID19 by Christ Community Health Services
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.
By submitting this form, you agree to allow Christ Community Health Services to send you results via testing messaging using the number provided here. If you disagree, uncheck the box but this could delay notification of your results.
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