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
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
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
prevnext( X )
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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