New Patient Registration Form

New Patient Registration Form

COVID -19 Alternative Payment Form
Patient Information
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Assigned Gender at Birth *
Birth Date *

Month Day Year
Email Address *
Primary Phone *
Alternative Phone
Responsible Party

If different than above
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

My Products *

product

PCR COVID Test $ 159.00

The PCR COVID-19 Test is conducted via a minimally invasive nasal swab. It is currently the most accurate test on the market.

product

Antibody Test $ 85.00

The antibody test will determine your previous exposure to COVD-19. Additionally, COVID rich plasma is vital to fighting the pandemic.

Subtotal $ 0.00 Tax $ 0.00 Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Appointment *
Terms *
I certify that the above information is true and correct. *

Clear
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform