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COVID-19 Appointment Request

  1. Use this form to request an appointment to be tested for COVID-19. We will call you as soon as possible to schedule your test. We will attempt to call you three times on your cellphone before we will try and contact you by email.

  2. MM/DD/YYYY

  3. XXX-XXX-XXXX

  4. If under 18 years of age

  5. Ethinicity*

  6. Race*

  7. Sex*

  8. Symptoms*

    Please check all that apply

  9. if Yes, please specify:

  10. MM/DD/YYYY

  11. List name of person you were exposed to

  12. Leave This Blank:

  13. This field is not part of the form submission.