Covid-19 PCR Lab Test

Personal Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Date of Birth (DOB)

MonthDayYear
Gender*

MaleFemaleOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Drivers License/State Issued ID or Any Proof of Address

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Reason for testing (select one):*

Travel ( Full payment is required at the time of service )Covid-19 Exposure
Do you have insurance?*

YesNo
Do you fall under CARES ACT? :*

YesNo
For more infromation on the CARE ACT Please Click Here
Current Covid Test Price: $100*

In Person Payment
Insurance Company*
Insurance (Policy ID)*
Group #*
Take a photo of your insurance card (Front & Back)

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By writing your name below. You hereby confirm that the information you have given above is true, and that you will comply with the terms and conditions outlined above. You also agree that date of submission will be the date of your consent. *

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