COVID 19 Requisition
SOUTH AMBOY SCHOOL DISTRICT, NJ
Email (ACCURACY IMPORTANT for result delivery)
*
Confirmation Email
example@example.com
Name
*
First name
Last name
Date of Birth
*
/
Month
/
Day
Year
Date
Gender
*
Male
Female
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
City
State
Zip Code
Test Option
Insurance Carrier
Insurance ID# (Please do not include "dashes" or spaces)
SSN
*
Comments
40 character limit
"By clicking "Submit" you authorize and give consent to Capital Health to analyze your specimen as well as submit a claim associated with the testing of your specimen to your insurance company. If a check is sent directly to you from the insurance company for this testing, you agree to sign and send the check directly to Capital Health LLC."
*
I accept the terms
Submit
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