Language
English (US)
Patient Registration
Need Help? Email Us at backtoschooltesting@gmail.com
Name
*
First Name
Last Name
Email
*
example@example.com
Phone
*
Please enter a valid phone number.
DOB
*
-
Month
-
Day
Year
MM-DD-YYYY
Photo ID
*
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of
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Provider
*
Insurance ID
*
Insurance Card (Front)
*
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of
Insurance Card (Back)
*
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Patient Signature
*
Clear
Patient Consent
*
I confirm the above information is accurate for myself or my child and I consent for this data to be used for covid testing purposes only.
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