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Register for Testing
Location:
GA-DODGE-FAITH IN ACTION BAPTIST CHURCH
1046 College Street, Eastman GA 31023, US
MONDAY, TUESDAY and THURSDAYS 9 am to 2 pm
Patient Information
First Name
Middle Initial
Last Name
DOB
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1903
1902
1901
1900
1899
1898
1897
1896
1895
1894
Sex
Choose...
Male
Female
Unknown
Race
Choose...
Asian
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other Race
White / Caucasian
Unknown / Unreported
Ethnicity
Choose...
Not Hispanic or Latino
Hispanic or Latino
Unknown / Unreported
Phone Number
Social Security Number
Driver License/ID Number
U.S. Address
Address 2
City
State
Zip
Email
Payment Options
Free community test
I have insurance (Free Community Test)
Insurance
---------
Custom Insurance
Insurance not listed
Policy Number
Group Number
Custom State Required Questions
1. First Test?
Yes
No
Unknown
2. Employed in healthcare?
Yes
No
Unknown
3. Hospitalized?
Yes
No
Unknown
4. ICU?
Yes
No
Unknown
5. Resident in a congregate care setting (including nursing homes, residential care for people with intellectual and developmental disabilities, psychiatric treatment facilities, group homes, board and care homes, homeless shelter, foster care or other setting):
Yes
No
Unknown
6. Pregnant?
Yes
No
N/A
7. Symptomatic as defined by CDC?
What are the symptoms of COVID-19?
According to the CDC
:
People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
Yes
No
Unknown
Date of Symptom Onset:
