Corporate International Travel Form

Corporate & Event Travel Registration
If your employer or event has partnered with Chapel Health for Covid-19 testing please use this form.

Please contact us at (704) 412-3612 if you have any questions.

Press start to begin registration.
Select Employer or Event

Corporate & Event Travel Registration
Name

First NameLast Name
Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Gender
Passport Number
This 9 digit number is found on the information page of your passport.
Passport Country of Issuance

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Passport Date of Issuance

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Nationality

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race and Ethnicity

Other
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
COUNTY of Home Address
Email
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Test Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Test Time

Hour Minutes

AM/PM Option
Anticipated Travel Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
I, the undersigned testing participant, acknowledge that I have been given an opportunity to review a copy of the HIPAA PRIVACY NOTICE.
Signature

Corporate & Event Travel Registration

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