FREE RAPID & PCR TEST WITH INSURANCE

RAPID ANTIGEN & RT-PCR TESTS FORM WITH INSURANCE (US ONLY)

International insurance is not accepted, if uploaded their appointments will be cancelled without any notice
- Negative Results of antigen are confirmed with gold standard tests which is RT-PCR
- Medical Necessity Covid Tests are covered with valid insurance
Name of Insurance
Member ID
Testing Date

MonthDayYear
Date
Contact Information
Reason for COVID test?*

I have had Covid symptoms (cough, shortness of breath, fever, chills, muscle aches, body aches, vomiting, diarrhea, loss of taste or smell) or suspect close contact with a person with COVID in the last 14 days? (Medically necessary Covid testing is provided at no cost. You will need a valid government issued ID and your insurance card.)I need testing for travel or routine testing for work.
RAPID ANTIGEN TEST
RT-PCR TEST
I understand that i am responsible for services that are considered non-covered expenses by my insurer

ANTIGEN & PCR TEST FORM

(TO CONFIRM NEGATIVE ANTIGEN TEST RESULTS WE PERFORM GOLD STANDARD TEST WHICH IS PCR AS WELL)
Appointment Schedule
Unique ID
FAMILY MEMBERS WITH DIFFERENT TIMES CAN VISIT FOR APPOINTMENTS AT THE SAME TIME

WALKINS ARE WELCOME !!!!
Appointment*

Patient Demographic Information
Name*

First NameLast Name
Age
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Race/Ethnicity*
Patient Weight
Address*

Patient Address

Street Address Line 2

CityState

Zip CodeCountry
Patient Phone Number*
Email*
example@example.com
Additional Family Members

Family members with same insurance can continue adding their family, if they have different insurance please fill out separate application and upload proper insurance

RAPID ANTIGEN & RT-PCR TESTS FORM WITH INSURANCE (US ONLY)