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COVID-19 Follow Up Request

  1. 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.

  2. Sex*

  3. (XXX)XXX-XXXX

  4. If under 18 years of age

  5. Ethinicity*

  6. Race*

  7. Symptoms*

    Please check all that apply

  8. If yes, please specify

  9. List name of person you were exposed to

  10. Do you agree

    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.

  11. Leave This Blank:

  12. This field is not part of the form submission.