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  • Parent DOB

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  • Patient DoB

     
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  • COVID Testing Form
  • Please complete one form for every person in your party. Para Espanol clic aqui
  • Are you a member of the following groups: first responders, dispatchers, public works, teachers/school staff, or National Guard? *

  • Please select the option which best reflects your employment

  • What town do you work for?

  • Are you an existing CHC patient or have you been tested at a CHC COVID Facility previously? *

  • Patient First Name *

  • Patient Last Name *

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  • Patient Birth Month *

  • Patient Birth Day *

  • Patient Birth Year *

  • My Birth Date

     
  • Is the date of birth above correct? *

  • By providing my mobile or cellular number, I acknowledge the risks associated with receiving a text message as detailed in the Informed Consent for COVID-19 Testing document and, despite those risks, I request that results be delivered by text.
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  • Primary/Mobile Phone Number for Results *

  • Please confirm your primary/mobile phone number *

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  • Secondary/Home Phone Number

  • Please confirm your home phone number

  • Your Street Address *

  • Street 2

  • City *

  • Zip Code *

  • State *

  • Sex *

  • Race *

  • Race Other

  • Ethnicity *

  • Ethnicity Other

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Parent/Guardian Information

  • By checking this box, I agree to have my child tested for COVID

  • Parent First Name

  • Parent Last Name

  • Parent Phone

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  • Parent Birth Month

  • Parent Birth Day

  • Parent Birth Year

  • If you are done with this form, please select Submit. If you would like to submit another form for another person, please select Next Patient.
    Please click the button once. You will be brought to a confirmation page upon submission.