TB Test Clinic Appointments
Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Race
White
Black or African American
American Indian/Alaska Native
Asian
Native Hawaiian/ Pacific Islander
Decline to Specify
Other
Ethnicity
Latin or Hispanic Origin
Not of Latin or Hispanic Origin
Decline to Specify
Language
Reason for TB Test
*
For Employment
Volunteers
School Volunteer
School Employee
Assisted Living Resident
Assisted Living Employee
Other
Select all times you are available on Mondays (Appointments are from 8am-12pm, every 15 minutes)
*
All available times
Monday 8:00
Monday 8:15
Monday 8:30
Monday 8:45
Monday 9:00
Monday 9:15
Monday 9:30
Monday 9:45
Monday 10:00
Monday 10:15
Monday 10:30
Monday 10:45
Monday 11:00
Monday 11:15
Monday 11:30
Monday 11:45
Preferred Date
-
Month
-
Day
Year
Date
Please note: selected apppointment date and time are
not valid
until confirmed by a NCPH employee
Submit
Should be Empty: