Two-Step TB Test Form
Please complete this form to request and prepare for a two-step tuberculosis test and follow-up reading schedule.
Patient Details
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Please Select
Phone
Email
Text
Two-Step TB Test Scheduling
First Test Appointment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Preferred Location / Clinic Site
Preferred Second-Step Return Date / Follow-Up Window
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Screening And Consent
Prior TB test history / two-step TB test status
No prior TB testing
Prior TB test completed
Previously started two-step TB test
Unsure
Other
Clinic note
Submit
Should be Empty: