PCR COVID-19 TEST (Free)

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Preferred Testing Location* This field is required.Please choose only one location. Please call the selected location prior to submitting this form to confirm the testing hours.
MTM Pharmacy - 12666 Brookhurst S, Ste 110, Garden Grove, CA 92840 P: (714)705-6992
MTM Pharmacy Bolsa Medical - 6552 Bolsa Ave, Ste A, Huntington Beach, CA 92647 P: (714)916-5383
MTM Pharmacy Caremore Anaheim - 1172 Euclid St, Anaheim, CA 92801 P: (714)613-1971
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Name* This field is required.Tên
First Name
Last Name
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Gender* This field is required.Giới tính
Male
Female
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Address* This field is required.Địa chỉ
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
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Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
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Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
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Greece
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Guinea-Bissau
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Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
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Jamaica
Japan
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Jordan
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Kiribati
North Korea
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Kosovo
Kuwait
Kyrgyzstan
Laos
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Lesotho
Liberia
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Liechtenstein
Lithuania
Luxembourg
Macau
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Madagascar
Malawi
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Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
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Monaco
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Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
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Nigeria
Niue
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Turkish Republic of Northern Cyprus
Northern Mariana
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Oman
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Paraguay
Peru
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Poland
Portugal
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Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
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Saudi Arabia
Senegal
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South Africa
South Ossetia
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eSwatini
Sweden
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Yemen
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Zimbabwe
Other
Country
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Date of Birth (month/day/year)* This field is required.Ngày Tháng Năm Sinh
mm-dd-yyyy
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Phone Number* This field is required.Số Điện Thoại
Please enter a valid phone number.
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Email* This field is required.
example@example.com
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INSURANCE NAME* This field is required.Tên Bảo hiểm Sức Khoẻ
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INSURANCE POLICY ID#* This field is required.Số Bảo hiểm
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Take Photo of The FRONT of Your Insurance Card. Chụp hình mặt trước của thẻ bảo hiểm
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Take Photo of The BACK of Your Insurance Card. Chụp hình mặt sau của thẻ bảo hiểm
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Preferred Arrival Time (Garden Grove)*Patients with confirmed arrival time will receive priority in testing. Everyone else is welcome to walk-in, and services will be done on a first-come first-served basis. If coming together in one car, please have only one person reserve a time slot. Xin quý vị vui lòng chọn giờ hẹn đến xét nghiệm, hoạc có thể chờ tới lượt nếu không có giờ hẹn. Nếu quý vị đi chung một xe, xin chỉ có một người lấy giờ hẹn.
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Preferred Arrival Time (Huntington Beach)*Patients with confirmed arrival time will receive priority in testing. Everyone else is welcome to walk-in, and services will be done on a first-come first-served basis. If coming together in one car, please have only one person reserve a time slot. Xin quý vị vui lòng chọn giờ hẹn đến xét nghiệm, hoạc có thể chờ tới lượt nếu không có giờ hẹn. Nếu quý vị đi chung một xe, xin chỉ có một người lấy giờ hẹn.
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Preferred Arrival Time (Anaheim)*Patients with confirmed arrival time will receive priority in testing. Everyone else is welcome to walk-in, and services will be done on a first-come first-served basis. If coming together in one car, please have only one person reserve a time slot. Xin quý vị vui lòng chọn giờ hẹn đến xét nghiệm, hoạc có thể chờ tới lượt nếu không có giờ hẹn. Nếu quý vị đi chung một xe, xin chỉ có một người lấy giờ hẹn.
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**Important, Please Read**

Notes to our Clients and Patients:

Khi quý vị đến nơi, xin đừng bước vào tiệm thuốc, xin đậu xe và gọi vào số điện thoại và cho nhân viên chúng tôi biết quý vị đang ngồi trong xe nào. Kết quả sẽ được gởi qua email của quý vị.

Please go to the MTM Pharmacy Location that you have contacted to receive your test. Results will be available via EMAIL and TEXT after 48-72 hours from SDI Labs.

When you arrive at the testing site, please DO NOT enter the pharmacy. Please park and wait in your car, then call the phone number of that pharmacy location and provide staff with your car information (color, make, last 3 digit of your license plate, parking location).

An Image of Your Insurance Card (both front and back) will be required before the test is performed. If you do not know how to send photos of your insurance card, please contact the pharmacy.

MTM Pharmacy Garden Grove:

12666 Brookhurst St, Ste 110, Garden Grove, CA 92840

P: (714) 705-6992

MTM Pharmacy Bolsa Medical

6552 Bolsa Ave, Ste A, Huntington Beach, CA 92647

P: (714) 916-5383

MTM Pharmacy Caremore Anaheim

1172 N Euclid St, Anaheim, CA 92801

P: (714) 613-1971
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