Patient Location:
This form is only to be completed by people living in Eastern Jackson County, which consists of all geography in Jackson County except for the city limits of Kansas City. If your address is in the Kansas City limits, or you live outside of Jackson County, you WILL NOT be able to proceed forward. This form is ONLY being monitored during business hours, Monday - Friday.
Symptoms
What symptoms are being experienced right now? (check as many as apply)
*
Headache
Fever (greater than 100.4 degrees)
Shortness of Breath
Chills/Nigh Sweats
Muscle Aches and Pains
Runny Nose
Sore Throat
Cough
Lost Sense of Taste/Smell
Fatigue
Sneezing
Diarrhea
Nausea
Rash
None of the Above
Other Symptoms
How severe are these symptoms (1 = mild and 10 = severe)
Do you (the patient) have a history of any of the following pre-existing medical conditions?
High Blood Pressure/Heart Disease
Diabetes
Asthma
Chronic Lung Disease
Kidney Failure
Chronic Liver Disease
Cancer
None of the Above
Prefer Not to Answer
Are you immunocompromised?
Yes
No
I Don't Know
On or about what date did symptoms begin?
-
Year
-
Month
Day
Date
Contact Information
Are you reporting symptoms for yourself or someone else in your household?
Self
Someone Else
Relationship to Person with Symptoms
I am their Mother
I am their Father
I am their Legal Guardian
I am their Friend or Other Family
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Date of Birth
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sex
*
Female
Male
Other
Race/Ethnicity (check as many as apply)
White
Black or African American
Hispanic or Latino
Asian or Pacific Islander
American Indian or Alaskan Native
Some other race
Insurance
This will only be used in the event that you get tested. A staff member can discuss your options with you if you choose to be contacted.
Insurance Holder Name
First Name
Last Name
Insurance Holder Date of Birth
-
Month
-
Day
Year
Date
Insurance Holder Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What insurance type do you have?
PPO
HMO
Other
What is your insurance policy number?
Please upload a picture of your insurance card. (front and back)
Browse Files
Cancel
of
Contact Information
This information will remain confidential. Your personal contact information will only be used if you wish to have someone follow up.
Would you like someone to contact you about these symptoms?
Yes
No
No Preference
Is there anything else we should know about these symptoms or your situation?
Submit
Should be Empty: