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COVID-19 Follow Up Request
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COVID-19 Follow Up Request
Use this form to request information regarding full case investigations, status or release letters. You can also call (620)604-1066 and leave a message if needed. We will get back to you as soon as possible.
First Name
*
Last Name
*
Date of Birth
*
Date of Birth
Sex
*
Male
Female
Address
*
City
*
State
*
Zip
*
Phone Number
*
(XXX)XXX-XXXX
Employer/School
Parent/Guardian Name
If under 18 years of age
Ethinicity
*
Non-Hispanic
Hispanic
Unknown
Race
*
White
Black
Asian
American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Date that symptoms began (Onset of Symptoms)
*
Date that symptoms began (Onset of Symptoms)
Symptoms
*
Please check all that apply
Asymptomatic (no symptoms)
Cough
Shortness of breath
Difficulty breathing
Sore Throat
Loss of smell/taste
Chills
Sweats
Muscle aches
Headache
Fatigue/Tired
Pneumonia
Diarrhea
Nausea/vomitting
Congestion/running nose
Acute Respiratory Distress Syndrome
Immunocompromised/Chronic Conditions?
*
If yes, please specify
Exposure
List name of person you were exposed to
Primary Care Provider
Additional Information
Email address
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By submitting this form, you understand that we will call you as soon as possible but if your symptoms get worse you will need to contact your Primary Care Provider or call 911.
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