COVID-19 Rapid Antigen Appointment Request Form

Appointment Request
COVID-19 Rapid Antigen Test 125$
DISCLAIMER:
- Rapid Antigen Test (Negative 90%, Positive 99% ACCURACY)
- Self swab ( We only Collect Samples and analyze)
- Cancellation/ Reschedule : 25$ Fee within 24 hours
Full Name*
First NameLast Name
Phone*
Area CodePhone Number
E-mail*
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Appointment
I would like to be notified about promotional services. Please note that we do not rent or sell your information to any third parties!*
YesNo
INSTRUCTIONS:
once you arrive to our location, Please remain in your car and call us at 909-333-4567, someone will go out and assist you. Please be seated in your car and leave the window one inch open in order for us to communicate with you
Should be Empty: