Rapid COVID-19 Testing Purchase Form

Rapid COVID-19 Testing
Cope and Fedullo Medical Services PLLC
First Name
Last Name
Date of Birth
MonthDayYear
Gender
Ethnicity
Race (Check all that apply)
Other
Phone Number:
Format: (000) 000-0000.
E-mail

Confirmation Emailexample@example.com
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Street Address
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Employed (EMP) or Student (STU) (If Neither skip to next question)
Name of Employer or School
Address of Employer or School
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Employer or School Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you currently have any symptoms of COVID-19 such as fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting or diarrhea?
Have you had close exposure to someone with COVID-19 in the last 10 days?
Have you tested positive for COVID-19 in the last 10 days?
Appointment
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Rapid COVID-19 Testing
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$60.00

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Total
$0.00
Credit Card
Your test report will take approximately 25 minutes to prepare. You can return at that time for a written report or we can text you the result (we call you if it is positive) and email you a written report.
To text you the result which cell phone carrier do you use?
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Rapid COVID-19 Testing