Travel Test Registration

Legal Name*

First NameLast Name
Thank you for visiting our page.

Travel Test sign-ups are not currently available. To sign up for testing please visit the following provider: www.bccovidtest.com/
For Appointments Please head to link below.
Date of Birth:*

MonthDayYear
Date
Gender*

MaleFemaleOther
Appointment - Drive-up Testing (Please only make an appointment if you intend to show, thanks!)*
Cell Phone Number (US Phone Number)*
Please enter a valid US phone number.
Email*
example@example.com
Address (US Address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Name*

AetnaAmerigroupAmeriHealthAnthemCignaEmblem HealthEmpireFidelisHorizonMedicaremeritainOscarOxfordUnited HealthcareNo InsuranceOther
Insurance Information - if uninsured write N/A

State / Province

Postal / Zip Code
Insurance Information *

State / Province

Postal / Zip Code
Social Security or US Driver's License (Only for uninsured patients)
Upload Front of Insurance Card (or ID for uninsured patients) *

Browse Files

Cancelof
Symptoms/Reasons for getting tested*
Is the patient pregnant?

YesNo
Passport Number and Country
I have read your HIPAA compliant privacy policy and I agree to the terms

I agree
Signature of Patient or Parent/Guardian*

Clear
Should be Empty: