COVID-19 TESTING Form
Happy Family Care & Clinic
Best person to contact in case of emergency?
Their relationship to you/phone #
Primary Insurance Information:
NAME of Policy Holder:
Relationship self/spouse/child other:
Employer Phone Info:
PLEASE make a front and back copy of your insurance card & forward to us. Our email address is: email@example.com
Please click submit below. You will be redirected to book your virtual or in-person appointment.
Should be Empty:
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