COVID-19 Follow Up Request

2. 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.

   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.

4. First Name*

5. Last Name*

6. Date of Birth*
   Date of Birth

7. Sex*

   1. Male
   2. Female

9. Address*

11. City*

12. State*

13. Zip*

15. Phone Number*

    (XXX)XXX-XXXX

16. Employer/School

17. Parent/Guardian Name

    If under 18 years of age

19. Ethinicity*

    1. Non-Hispanic
    2. Hispanic
    3. Unknown

20. Race*

    1. White
    2. Black
    3. Asian
    4. American Indian/Alaskan Native
    5. Native Hawaiian/Pacific Islander

21. Date that symptoms began (Onset of Symptoms)*
    Date that symptoms began (Onset of Symptoms)

23. Symptoms*

    Please check all that apply

    1. Asymptomatic (no symptoms)
    2. Cough
    3. Shortness of breath
    4. Difficulty breathing
    5. Sore Throat
    6. Loss of smell/taste
    7. Chills
    8. Sweats

    1. Muscle aches
    2. Headache
    3. Fatigue/Tired
    4. Pneumonia
    5. Diarrhea
    6. Nausea/vomitting
    7. Congestion/running nose
    8. Acute Respiratory Distress Syndrome
24. Immunocompromised/Chronic Conditions?*

    If yes, please specify

26. Exposure

    List name of person you were exposed to

27. Primary Care Provider

28. Additional Information

30. Email address

32. Do you agree

    1. I 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.

Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field