SHP Linden NJ Form

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Select type of COVID-19 Test at Super Health Pharmacy Linden NJ* This field is required.Testing Starts At 9:30 AM Daily!
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
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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)
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Patient Name* This field is required.
First Name
Last Name
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Middle Initial
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Date of Birth* This field is required.MM-DD-YYYY
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Patient Address * This field is required.
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City* This field is required.
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State* This field is required.
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ZIP Code* This field is required.
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Cell Phone* This field is required.
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Gender* This field is required.
Male
Female
N/A
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COVID 19 (SARS CoV 2 Assay) via Nasal Swab* This field is required.
COVID 19 (SARS CoV 2 Assay) via Nasal Swab
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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
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Email *
example@example.com
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Picture of Government Issued IDDrivers License, Passport, Etc
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Picture of Insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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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
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Tags
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