Event Registration

Event Appointment Form

Please fill out the form below to confirm your appointment.
Please Select the Event
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth (Must be 18 or over)*

MonthDayYear
Date
Sex*

MaleFemalePrefer not to disclose
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Vaccine Status*

I am not vaccinatedPartially vaccinatedFully vaccinatedHad booster
Medical History*

Fever or chillsCoughShortness of breath or difficulty breathingFatigueMuscle or body achesHeadacheNew loss of taste or smellSore throatCongestion or runny noseNausea / vomiting or diarrheaNo symptoms
Race

African American / BlackAmerican IndianAsianCaucasian / WhiteHispanicOther
Primary Insurance Holder Name
Insurance Company Name
Insurance Policy #
Patient Relation to Insurance Subscriber
Primary Holder/Subscriber Employment State
Employer
Upload Photo of License

Cancelof
Upload Photo of Insurance Card

Cancelof
Vaccine Event Registration*
Mock Event 2 Calendar*
I would prefer to have my results:*

Emailed to me (if selected, you MUST sign below)Call me
Signature

Clear
If signed by someone other than the patient, please state your name, relationship to the patient, and a description of your authority to act on the patient’s behalf.
Name

First NameLast Name
Relationship to Patient / Authority
*DISCLAIMER - PLEASE READ
- EVERY person who is being tested needs to fill out a separate registration form. Individuals who are not registered will not be given a COVID-19 test upon arrival.
- Inclement weather may cause the delay or postponement of your appointment. Please check your email prior to your appointment for any notifications.
Should be Empty:

Event Appointment Form