San Antonio Covid-19 Rapid Testing Cares Act Patient Registration

Covid-19 Rapid Testing Cares Act Patient Registration
No wait, results in 15 minutes
PLEASE NOTE THAT THIS IS ONLY FOR PATIENTS WITHOUT HEALTH INSURANCE

If you do not have health insurance, we can offer you a no cost free rapid Covid-19 test.
Select Location*

Austin Hwy - 1756 Austin Hwy San Antonio, TX 78218Culebra Road - 8031 Culebra Rd. San Antonio, TX 78251Hildebrand - 1107 W. Hildebrand St. San Antonio, TX 78201Nacogdoches - 14000 Nacogdoches Rd. San Antonio, TX 78247Potranco Road - 11912 Potranco Rd. San Antonio, TX 78253West Ave - 11743 West Ave. San Antonio, TX 78216Pleasanton Road - 2026 Pleasanton Rd. San Antonio, TX 78214Gramercy Place - 907 W. Gramercy Pl. San Antonio, TX 78201San Marcos - 730 E. Hopkins St. San Marcos, TX 78666 (next to Five Guys)
Billing TIN*
Patient Name*

First NameMiddle NameLast Name
Patient Date of Birth*

MonthDayYear
Date
ID Type*

SSNDriver License
ID Number*
Patient Gender*

MaleFemale
Patient Account Number*
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code
Service Type*

Professional
Date of Service*

MonthDayYear
Date
Date of Admission

MonthDayYear
Date
Date of Discharge

MonthDayYear
Date
Patient Phone Number*
Please enter a valid phone number.
Patient Email*
example@example.com
Provide Photo of ID
With my signature below, I confirm that all information provided in this form is true and accurate. I understand that if I provide false or inacurrate information, then it is considered FRAUD, with the potential to be punished by the fullest extent of the law.
Signature*

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Covid-19 Rapid Testing Cares Act Patient Registration

No wait, results in 15 minutes