COVID-19 Rapid Antigen Appointment Request Form

Appointment Request

COVID-19 Rapid Antigen $75 (15 minutes results). Test is self pay, we Can’t bill insurance for this test.
DISCLAIMER: Rapid Antigen Test (Sensetivity 84-96%, Specificity 99-100%) Self swab ( We only Collect Samples and analyze). For more information about the test click HERE Our address is 31201 US Highway 19N, Palm Harbor, FL 34684
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Reason for Testing*
Gender at birth*
Race*
Ethnicity*
Cell Phone*

Area CodePhone Number
Appointment*
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
INSTRUCTIONS: once you arrive to our location, Please remain in your car and call us at 727-772-6868, someone will go out and assist you. Please be seated in your car and leave the window few inches open in order for us to communicate with you. The results of this test are reportable to the Florida department of Health.

COST OF RAPID TEST IS $75
Form of Payment
Last 4 Digits of Credit card number ( WE WILL TAKE FULL CARD NUMBER OVER THE PHONE WHEN YOU ARRIVE FOR THE TEST)*
Last 4 digits
Expiration date MM/YY*
Billing Zip code*
I agree and will comply with instructions above and I authorize billing my credit card if applicable in the amount of $75: Signature*

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