COVID-19 Test Request

COVID-19 Test Request
Patient Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ethnicity

HispanicNot Hispanic
Email
example@example.com
Phone Number

Area CodePhone Number
Primary Care Doctor

First NameLast Name
Patient Health Information
Date of Symptom Onset*

MonthDayYear
Date
Height
Weight
Medical Conditions

DiabetesHypertensionChronic Kidney DiseaseCardiovascular DiseaeChronic Obstructive Pulmonary Disease (COPD) / other chronic respiratory diseaseImmunosuppressive DiseaseCurrently receiving immunosuppressive treatment
I certify to the best of my knowledge; this information is accurate.
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Confirm Request and Agree to Terms
Total due now includes the medical provider review and platform fees only. By clicking"Submit", you indicate that you, as the patient or legal guardian of the patient, agree:
1. to follow up with my regular medical provider for ongoing care;
2. to the best of my knowledge, all information submitted is accurate;
3. to the Terms of Service and Consent to Telehealth.
4. I understand that the total due now does not include any POC fees and that I am responsible for any fees billed by the Pharmacy.

Available Test

COVID-19 Antigen Test$100.00

* (Due at Point of Care) If you will pay over the phone use coupon code: PAYLATER

Enter coupon

Total $0.00

Pay with PayPal

Please click one of the PayPal options to complete payment and submit the form.
Should be Empty:

Patient Health Information