TB Test Clinic Appointments

TB Test Clinic Appointments
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Race

WhiteBlack or African AmericanAmerican Indian/Alaska NativeAsianNative Hawaiian/ Pacific IslanderDecline to SpecifyOther
Ethnicity

Latin or Hispanic OriginNot of Latin or Hispanic OriginDecline to Specify
Language
Reason for TB Test*

For EmploymentVolunteersSchool VolunteerSchool EmployeeAssisted Living ResidentAssisted Living EmployeeOther
Select all times you are available on Mondays (Appointments are from 8am-12pm, every 15 minutes)*

All available timesMonday 8:00Monday 8:15Monday 8:30Monday 8:45Monday 9:00Monday 9:15Monday 9:30Monday 9:45Monday 10:00Monday 10:15Monday 10:30Monday 10:45Monday 11:00Monday 11:15Monday 11:30Monday 11:45
Preferred Date

MonthDayYear
Date
Please note: selected apppointment date and time are not valid
until confirmed by a NCPH employee
Should be Empty: