Mesa County COVID-19 Testing Registration

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Please complete this form for the day you will be getting tested for every individual.

Testing will be open from 10am-6pm

Please select a time slot - limit 15 per 15 minutes *

The Last 4 Digits of Your Phone Number *

First Name *

Middle Initial

Last Name *

Date of Birth *

YYYY

Sex Assigned at Birth *

Male

Female

Unknown

Other

Not applicable

Ambiguous

Intersex

Prefer Not to Say

Race

Native Hawaiian_Pacific Isl

White

Black

Other

American Indian/Alaskan Native

Asian

Clear selection

Ethnicity

Not Hispanic

Hispanic

Unknown

Clear selection

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Which symptoms are you experiencing? *

Fever over 100.4F

Felt Feverish

Chills

Muscle Aches

Headache

Runny Nose

Sore Throat

Cough

Fatigue

Diarrhea

Nausea or Vomiting

Shortness of Breath

Abdominal Pain

Loss of Taste or Smell

Increased Need for Oxygen

NONE

Required

Symptom Onset Date

YYYY

Submit

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