COVID-Testing Form
Administration Date
*
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Race
*
White
Black or African American
Asian
Other Race
Gender
*
Male
Female
Ethnicity
*
Hispanic
Non-Hispanic
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you Insured?
Yes
No
Relation to Insured
Self
Spouse
Child
Other
Primary Insurance
*
Policy Number
*
Are you experiencing any of the following symptoms? Sore throat, Cough, Fever, Shortness of breath, Diarrhea, Headache, Body aches, Nausea / Vomiting, Loss of Taste / Smell?
*
Yes
No
Has anyone in your household, or any of acquaintances tested positive for COVID-19 within the last 14 days?
*
Yes
No
Any recent travels outside of the State or Country?
*
Yes
No
Take Photo of Insurance Card
Take Photo of ID (Drivers License, Passport, State Issued ID)
Please Sign our Consent Form:
*
I certify that the information provided on this form is accurate. I authorize the place of service to release the results of this test to the ordering provide. I further authorize the lab and the ordering provider to bill my insurance and to receive payment of benefits for the test ordered. I authorize the lab and the ordering provider to release to my insurance provider any medical information necessary to process this claim. I consent and give permission to the provider to contact me to discuss about the test results.
COVID-19 Test
Please Select
RAPID ANTIGEN
LAB RT-PCR
MOLECULAR PCR
FLU/RSV/COVID Test
Please Select
FLU/RSV/COVID
Strep Testing
Please Select
STREP TEST
COVID-19 Bivalent Booster Vaccine
Please Select
Pfizer-BioNTech
Moderna
Flu Vaccine
Please Select
Flu Shot
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