New Patient Registration Form

New Patient Registration Form

COVID -19 Alternative Payment Form
Patient Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

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

MonthDayYear
Email Address*
Primary Phone*
Alternative Phone
Responsible Party

If different than above
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / 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 $0.00Tax $0.00Total $0.00

Credit Card

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

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