COVID 19
Please complete the following information in advance if your appointment.
Book an Appointment for
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COVID-19 Rapid Antigen Test ($115)
Your Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Date of Birth
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Month
-
Day
Year
Gender
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Male
Female
Rather No Say
Other
Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your Race?
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Ethnicity
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Have you been in contact with someone who has been exposed to COVID-19 or has a confirmed case of COVID-19?
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Yes
No
In the last 48 hours, have you had any of the following symptoms?
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fever of 100f (37.7 C) or above/ possible fever symptoms like alternative chills and sweating
Cough
Trouble breathing/shortness of breath or severe wheezing
Loss of taste
Nausea
Vomiting
Runny nose
New Choice (3)
Difficulty sleeping
Diarrhea
Fatigue
Headache
None of the Above
Other
Have you or anyone in your household traveled outside of the State of New Jersey in the past 14 days?
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Yes
No
Do we have permission to text you or leave a message on your phone?
*
Yes
No
Is there anything else we should know about your reason for coming in for a COVID-19 test?
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How did you hear about us?
From a Friend
Drove by
Facebook
Currently a patient in the office
Other
Due to high demand of tests, we do not allow cancellations. Once payment is made, the Rapid test is non-refundable. By clicking yes, you agree to these terms.
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Yes
Available Appointments
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