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.
Submit
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