COVID 19 Requisition
JERSEY CITY EXCHANGE PLACE
Email (ACCURACY IMPORTANT for result delivery)
Date of Birth
Please enter a valid phone number.
Insurance ID# (Please do not include "dashes" or spaces)
40 character limit
"By clicking "Submit" you authorize and give consent to Capital Health to analyze your specimen as well as submit a claim associated with the testing of your specimen to your insurance company. If a check is sent directly to you from the insurance company for this testing, you agree to sign and send the check directly to Capital Health LLC."
I accept the terms
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