Travel COVID-19 Test Order Form

Travel COVID-19 Test Order Form
Order your COVID-19 test for travel. Please fill out all required information to schedule your test and receive your results on time.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Travel Destination Country
Date of Travel
MonthDayYear
Date
Type of COVID-19 Test
Other
Preferred Test Appointment
How would you like to receive your test results?
Special Instructions or Medical Notes
Order Your COVID-19 Test
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PCR Test
Standard PCR test for travel purposes. Results within 24-48 hours.
$120.00

Rapid Antigen Test
Rapid antigen test for travel purposes. Results within 1 hour.
$80.00

Total
$0.00
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