Health Center Listing Request Form

Thank you for your interest in including a link to your health center's COVID-19 testing website. Please provide the following information regarding COVID-19 testing at your health center.

Health Center Name:*

Please provide a link to your health center's public-facing COVID-19 testing information (URL):*

Does your health center's COVID-19 testing website clearly state the times and days testing is available?*

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If COVID-19 testing is available at multiple locations, days, and times, please provide these details below:*

Does your health center have a specific phone number to call regarding COVID-19 testing?*

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If you answered yes, please provide the number below. If you answered no, leave blank.

Is there a cost associated with receiving a COVID-19 test at your health center?*

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Does your health center require a wellness check prior to getting tested for COVID-19?*

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If you answered yes, is there a cost associated with the wellness check? If you answered no, leave blank.

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Are COVID-19 tests EXCLUSIVELY for health center patients?*

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Please briefly explain your health center's process for communicating positive and negative COVID-19 test results to the client:*

What is the turnaround time for communicating COVID-19 test results to your health center's patients? (time from when the test is administered to when the patient receives the result)*

Please enter any comments or questions below:

Who should our web team contact if there are any questions regarding your Health Center’s Listing Request Form? Please provide a name, e-mail address, and phone number. This information will not be shared publicly.*

Name, E-mail Address, Phone Number

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