COVID-19 Patient Screening

This form should only be completed and submitted once per person. After submitting, you will be placed in line and contacted as soon as possible. Appointment schedulers are operating 8 a.m.-5 p.m., Monday-Saturday.
Submitting this form more than once or submitting the form AND calling the phone line will not speed up the process.
Thank you.

The scheduling for the West Street Farmers Market – Jackson MS location has temporarily been suspended. The site has been booked out through Monday 7/13/2020 at this point. Request for appointments will resume on Tuesday July 7th.

* - Required Fields

Last Name*
First Name*
Middle Name
Suffix
Birth Date*
Street Address (no PO Box or RR #))*
City, State, Zip Code*	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY -
County*	Adams Alcorn Amite Attalla Benton Bolivar Calhoun Carroll Chickasaw Choctaw Claiborne Clarke Clay Coahoma Copiah Covington DeSoto Forrest Franklin George Greene Grenada Hancock Harrison Hinds Holmes Humphreys Issaquena Itawamba Jackson Jasper Jefferson Jefferson Davis Jones Kemper Lafayette Lamar Lauderdale Lawrence Leake Lee Leflore Lincoln Lowndes Madison Marion Marshall Monroe Montgomery Neshoba Newton Noxubee Oktibbeha Panola Pearl River Perry Pike Pontotoc Prentiss Quitman Rankin Scott Sharkey Simpson Smith Stone Sunflower Tallahatchie Tate Tippah Tishomingo Tunica Union Walthall Warren Washington Wayne Webster Wilkinson Winston Yalobusha Yazoo
Home Phone Number*	() -
Cell Phone Number*	() -
Can this number receive a text message?*	Yes No
Email Address
Select your preferred location*   Choctaw - Ackerman - 7/8 Copiah - Hazelhurst - 7/9 Jones - Laurel - 7/11 Kemper - DeKalb - 7/10 Lee - Tupelo - 7/7 Madison - Canton - 7/10 Marshall - Holly Springs - 7/9 Sunflower - Indianola - 7/8 Walthall - Tylertown - 7/7 Winston - Louisville - 7/11 Select a time 8 a.m. – 9 a.m. 9 a.m. – 10 a.m. 10 a.m. – 11 a.m. Noon – 1 p.m. 1 p.m. – 2 p.m. 2 p.m. – 3 p.m. Select a time Noon – 1 p.m. 1 p.m. – 2 p.m. 2 p.m. – 3 p.m. 3 p.m. – 4 p.m.
Race*	American Indian / Alaska native Asian Black Pacific Islander / Hawaiian White / Caucasian Other
Ethnicity*	Hispanic or Latino Non-Hispanic or Latino
Sex*	Female Male
Do you have a cough, fever, shortness of breath, sore throat, or other respiratory symptoms?*   Yes No Symptoms What are your symptoms?
Have you been exposed to someone you know is positive for COVID-19?*   Yes I have No I have not According to Mississippi State Department of Health recommendations, you are not eligible for COVID-19 testing at this time. It is still possible that you may be infected with COVID-19 or become infected in the future. We recommend that you go to www.cdc.gov to review the most current guidelines for care at home. Should your condition change or you believe you have become exposed to a person confirmed to be infected in the future, please reach out to us again for assessment.