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Testing Registration Form

First Name

Last Name

Mobile Number

Address

City

State

Zip

Gender

Date of Birth

Please briefly describe your symptoms

255 character limit

0 / 255

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

Who is your primary care provider (choose from the drop down list)

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.