Georgia Department of Public Health COVID-19 Test Referral:

This test referral form is to identify if your patient meets the criteria for testing. Please answer the questions below. If your patient does not meet the criteria you will be given a notice. If they meet the criteria, you will be directed to complete the Specimen Point of Collection(SPOC) referral form. Once you fill out the referral form you will receive a PUI number for your patient. Please be sure and select the appropriate SPOC location for your patient. A list of facilities will be available on the referral form.

1 . Does your facility have the capacity to collect specimens for COVID-19 testing?Yes No 
2 . Is this patient experiencing symptoms of COVID-19 (i.e. fever, cough, shortness of breath, chills, repeated shaking with chills, headache, sore throat, muscle pain, and new loss of taste or smell ) OR is the patient asymptomatic but would like to be tested?Yes No