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PCHD COVID-19 Testing Registration Form
So as to be respectful of your time, and in an effort to expedite the testing process, please complete this short form prior to your arrival at the testing site. Please be sure to have your government-issued photo identification with you (if applicable and available) at the time of testing. In all, this registration process takes only 2-5 minutes to complete.
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  • English (US)
  • 1
    Select any and all that apply.
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  • 2
    For the purposes of COVID-19 screening, "close contact" is defined by the Centers for Disease Control and Prevention as "having been within 6 feet of an infected person for at least 15 minutes starting from 2 days before illness onset (or, for [those without symptoms], 2 days prior to positive specimen collection) until the time the patient is isolated."
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  • 3
    Please enter a number between 0 and 14.
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  • 4
    A fever (100.4º or higher), new/worsening cough, new/worsening shortness of breath, new/worsening muscle or body aches, new/worsening fatigue, new/abnormal sore throat, new/worsening/abnormal congestion or runny nose, new/worsening/abnormal diarrhea, new loss of taste, new loss of smell, or nausea/vomiting.
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  • 5
    Please select all that apply.
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  • 6
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  • 7
    Pick a Date
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  • 8
    Please provide your FULL LEGAL NAME, as it is listed on a government-issued identification card.
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  • 9
    Pick a Date
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  • 10
    Although not required, providing the last four digits of your social security number can prevent issues with billing insurance providers and/or reporting test results in an accurate and timely manner. We do strongly encourage that patients provide their social security number to prevent such issues. Please note that this form is compliant with all patient privacy regulations, as is required by HIPAA and the HITECH Act.
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  • 11
    • Male
    • Female
    • Other
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  • 12
    Please mark all that apply.
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  • 13
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  • 14
    Please provide a valid email address. By providing your email address, the contracted lab may provide you with access to your test results via a patient portal and you are provided with the opportunity to sign up for notifications for when vaccine is available to the general public in your local area.
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  • 15
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  • 16
    Please provide the physical address of your PRIMARY residence. PLEASE DO NOT UTILIZE A POST OFFICE BOX, AS YOU WILL BE ASKED TO PROVIDE A VALID 911 ADDRESS AT THE TIME OF TESTING.
    Please Select
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    • United States
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    • The Bahamas
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    • Bangladesh
    • Barbados
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    • Bolivia
    • Bosnia and Herzegovina
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    • Brunei
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    • Burkina Faso
    • Burundi
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    • Cameroon
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    • Cape Verde
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    • Chile
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    • Christmas Island
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    • Colombia
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    • Gabon
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    • Gibraltar
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    • Greenland
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    • Guadeloupe
    • Guam
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    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
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    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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  • 17
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  • 18
    To help public health officials understand the type of housing in which you reside, please enter a short description (no more than 2-3 words) of your housing type.
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  • 19
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  • 20
    Please provide your mailing address, if different than your physical address.
    Please Select
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curacao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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  • 21
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  • 22
    Please select any and all that apply.
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  • 23
    Please provide a brief description (1-3 words) of your employer type so that public health officials can better understand your type of employment.
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  • 24
    Please provide a valid telephone number where you can be reached if your test results indicate the presence of the COVID-19 virus.
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  • 25
    Simply click "Next" if you do not have a secondary phone number or if you do not wish to provide one at this time.
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  • 26
    NOTE: COVID-19 vaccinations are NOT currently available.
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  • 27
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  • 30
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  • 31
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  • 32
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  • 33
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  • 34
    Examples of medical insurance providers include Medicare, Medicaid, Aetna, PEIA, etc.
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  • 35
    Please enter your the information below from the insurance card provided to you by your primary medical insurance provider. If you do not have your policy number this information readily available, please be prepared to provide it at the time of vaccination. Please bring a copy of your medical insurance card with you at the time of vaccination.
    • Self
    • Spouse
    • Child
    • Other
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  • 36
    To speed up the registration and immunization process, you can take a picture of the front of your insurance card. If you wish to submit a photo of your insurance card, please click the button below to take a picture of the FRONT of your insurance card.
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  • 37
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  • 38
    Please click the button below to take a picture of the BACK of your insurance card.
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  • 39
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  • 40
    Please enter your the information below from the insurance card provided to you by your primary medical insurance provider. If you do not have your policy number this information readily available, please be prepared to provide it at the time of vaccination. Please bring a copy of your medical insurance card with you at the time of vaccination.
    • Self
    • Spouse
    • Child
    • Other
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  • 41
    To speed up the registration and immunization process, you can take a picture of the front of your insurance card. If you wish to submit a photo of your insurance card, please click the button below to take a picture of the FRONT of your insurance card.
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  • 42
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  • 43
    Please click the button below to take a picture of the BACK of your insurance card.
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  • 44
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  • 45

    PLEASE CLICK THE SUBMIT BUTTON BELOW TO FINALIZE YOUR APPOINTMENT REQUEST AND SUBMIT YOUR DATA TO THE PUTNAM COUNTY HEALTH DEPARTMENT.

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