COVID-19 Testing Authorization Form
Patient Name
*
First Name
Last Name
Phone Number
*
Email Address
*
Confirmation Email
Please enter the email address where you wish to receive your receipt and confirmation number.
Select Test:
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COVID-19 Nasopharyngeal PCR Test
$
75.00
COVID-19 Oral Rinse PCR Test
$
75.00
COVID-19 Rapid Test
$
50.00
COVID-19 Spike Antibody Test
$
53.10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Date of Submission
-
Year
-
Month
Day
Date
Hour Minutes
AM
PM
AM/PM Option
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