COVID-19 Testing form

COVID-19 TESTING Form

Happy Family Care & Clinic
Personal Information:
Full Name *

First Name Middle Name Last Name
DOB *
MM/DD/YYY
Gender *
Phone Number *

Area Code Phone Number
E-mail
Best person to contact in case of emergency?
Their relationship to you/phone #
Primary Insurance Information:
NAME of Policy Holder:
Their DOB:
Relationship self/spouse/child other:
Employer:
Employer Phone Info:
PLEASE make a front and back copy of your insurance card & forward to us. Our email address is: hfcareclinic@gmail.com
Thank You!

Please click submit below. You will be redirected to book your virtual or in-person appointment.
Should be Empty:

COVID-19 TESTING Form