Drive-Thru Testing Appointment Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Total Number of People for Swab Testing
Please Select
1
2
3
4
5
Additional Person Information
Select Appointment Time
Select Payment Option
Cash (On-Site Payment)
Credit Card (On-Site Payment)
Total Amount ($120.00 per person)
Guidelines
On the day of your appointment, please be ready 15 minutes early.
Please bring your valid government-issued ID.
Our professional medical staff will perform the swab test.
We will send your test results via e-mail.
Submit
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