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
Gender*

MaleFemale
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
Nationality*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race and Ethnicity*

American IndianAfrican AmericanAsianPacific IslanderCaucasianHispanicOther
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.
Test Date*

MonthDayYear
Test Time*

Hour Minutes

AM/PM Option
Anticipated Travel Date*

MonthDayYear
I, the undersigned testing participant, acknowledge that I have been given an opportunity to review a copy of the HIPAA PRIVACY NOTICE.
Signature*

Clear

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Corporate & Event Travel Registration