Hollywood, Florida Clinic
Covid-19 Testing at 510 North Dixie Hwy. Hollywood, FL 33020
Number Of Patients
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1
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Lead Patient Name
*
First Name
Last Name
Phone Number
E-mail
*
example@example.com
Date Of Birth
*
-
Month
-
Day
Year
Gender
*
Female
Male
If You Are Testing Due To Upcoming Travel Plans, Please Enter Departure Date.
-
Month
-
Day
Year
Date
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 2
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 3
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 4
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 5
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 6
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 7
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 8
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 9
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 10
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 11
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 12
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 13
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
*
Patient 14
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 15
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 16
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 17
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 18
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 19
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
Patient 20
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Please enter your passport number below if you'd like for us to include It On Your Report:
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Covid-19 PCR tests have a cut-off time of 7PM EST for next business day results.
Appointment Date And Time
*
A Med2u Inc. Representative will reach out to confirm your appointment time.
My Products
*
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COVID-19 RT PCR Test $ 200.00
$
200.00
Receive the lab report results in the evening of the following business day.
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Covid-19 Antigen Rapid Test $ 150.00
$
150.00
Receive results in 15-30 minutes
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Rapid Antibody IgG & IgM Test $ 100.00
$
100.00
Receive results in 20 minutes
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Total
$
0.00
Credit Card
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