Coronavirus

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COVID-19 Patient Screening

This form should only be completed and submitted once per person. After submitting, you will be placed in line and contacted as soon as possible. Appointment schedulers are operating 8 a.m.-5 p.m., Monday-Saturday.
Submitting this form more than once or submitting the form AND calling the phone line will not speed up the process.
Thank you.

COVID-19 Patient Screening

* - Required Fields

Last Name* 
First Name* 
Middle Name
Suffix
Birth Date*  
Street Address (no PO Box or RR #))* 
City, State, Zip Code*  -  
County*
Home Phone Number*() -    
Cell Phone Number*() -    
Can this number receive a text message?*
Email Address
Select your preferred location*  
Select a time
Select a time
Race*




Ethnicity*
Sex*
Do you have a cough, fever, shortness of breath, sore throat, or other respiratory symptoms?*  
What are your symptoms?
 
Have you been exposed to someone you know is positive for COVID-19?*  
 


According to Mississippi State Department of Health recommendations, you are not eligible for COVID-19 testing at this time. It is still possible that you may be infected with COVID-19 or become infected in the future. We recommend that you go to www.cdc.gov to review the most current guidelines for care at home. Should your condition change or you believe you have become exposed to a person confirmed to be infected in the future, please reach out to us again for assessment.