You can always press Enter⏎ to continue
Welcome to Super Health Pharmacy
Hi there, please fill out and submit this form.
START
1
Select type of COVID-19 Test at Super Health Pharmacy Linden NJ
*
This field is required.
Testing Starts At 9:30 AM Daily!
Lab PCR COVID Nasal Swab $0 with insurance (Results within 1-2 days)
Rapid Covid Test Nasal Swab (Results within 15 minutes) $89 (No appointment required) Super Health Pharmacy Linden NJ
Rapid COVID-19 PCR Nasal Swab Test $175 (Results within in 15 minutes) (No appointment required) Recommended for Travel, Medical Procedures, etc
Rapid Flu A & B Test (Results within 15 minutes) (No appointment required) $40
Previous
Next
Submit
Press
Enter
2
Appointment For COVID PCR Test (Results in 2-3 days)
For multiple family members, please only select one appointment! (Only 1 appointment needed per family/group)
Previous
Next
Submit
Press
Enter
3
Patient Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
4
Middle Initial
Previous
Next
Submit
Press
Enter
5
Date of Birth
*
This field is required.
MM-DD-YYYY
Previous
Next
Submit
Press
Enter
6
Patient Address
*
This field is required.
Previous
Next
Submit
Press
Enter
7
City
*
This field is required.
Previous
Next
Submit
Press
Enter
8
State
*
This field is required.
Previous
Next
Submit
Press
Enter
9
ZIP Code
*
This field is required.
Previous
Next
Submit
Press
Enter
10
Cell Phone
*
This field is required.
Previous
Next
Submit
Press
Enter
11
Gender
*
This field is required.
Male
Female
N/A
Male
Female
N/A
Previous
Next
Submit
Press
Enter
12
COVID 19 (SARS CoV 2 Assay) via Nasal Swab
*
This field is required.
COVID 19 (SARS CoV 2 Assay) via Nasal Swab
Previous
Next
Submit
Press
Enter
13
ICD-10 Code
*
This field is required.
Z20.828 Contact with and suspected exposure to other viral communicable disease
Z11.59 Asymptomatic, no known exposure, results unknown or negative
Previous
Next
Submit
Press
Enter
14
Email *
example@example.com
Previous
Next
Submit
Press
Enter
15
Picture of Government Issued ID
Drivers License, Passport, Etc
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
Previous
Next
Submit
Press
Enter
16
Picture of Insurance Card
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
Previous
Next
Submit
Press
Enter
17
Have you done a FREE PCR Test with us in the past? (If not, you will be redirected to the lab's self registration page, which MUST be completed to confirm your appointment.)
*
This field is required.
Yes
No
Yes
No
Previous
Next
Submit
Press
Enter
18
Tags
Todo
In Progress
Done
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
18
See All
Go Back
Submit