Corporate Testing*

1
Please Select a Testing Location:* This field is required.
Olmos Park (4401 McCullough Ave 78212 - Frog Car Wash)
On site with company listed previous (only pick this if we are coming to you)
2
Which Company are you with?* This field is required.
Silver Eagle Distributors
SHOOTERS FILMS
MISSION PARK
Hixon Properties
City of Olmos Park
Wings
Steve's and Sons
Lewis Energy
Casey Roy Designs
Ancira Auto Group (PCR Testing Only)
Crown Roofing & Remodeling
Hard Rock Drilling
Paloma Blanca Enterprises
Four Seasons OB/GYN
PMBG Law
The Argyle
Blackmon Garage
St. Anthonys
Billy Bob's Tire
Laurel Heights Weekday School
San Antonio Country Club (Rapid Antigen Testing Only)
Blanco Cafe
Olmos Park Vet
3
What type of test should be administered?* This field is required.PCR tests can take up to 24 hours when in high demand!
15 Antigen 1 HOUR PCR
4
Olmos Park please select a Date and Time* This field is required.⁸
5
PHTX- Unique ID
6
E-mail* This field is required.
example@example.com
7
Full Name* This field is required.
First Name
Last Name
8
Date of Birth* This field is required.(Tap year to get started)
Date
Month
Day
Year
9
Age* This field is required.
10
Gender* This field is required.Male = M Female = F Other = O
M
F
O
11
Race* This field is required.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Unknown
12
Ethnicity* This field is required.Hispanic = H Non- Hispanic = NH Unknown = U
H
NH
U
13
Phone Number* This field is required.Area Code and Phone Number XXX-XXX-XXXX
Area Code and Phone Number
14
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Country
15
County of Residence* This field is required.
16
Need to add another member from your household to this appointment?(If you have more than 5, please let us know)
First Name
Last Name
Date of Birth (mm/dd/year)
Age
Gender
Additional 1
Additional 2
Additional 3
Additional 4
Additional 5
Additional 1
Additional 2
Additional 3
Additional 4
Additional 5
First Name
Last Name
Date of Birth (mm/dd/year)
Age
Gender
First Name
Last Name
Date of Birth (mm/dd/year)
Age
Gender
First Name
Last Name
Date of Birth (mm/dd/year)
Age
Gender
First Name
Last Name
Date of Birth (mm/dd/year)
Age
Gender
First Name
Last Name
Date of Birth (mm/dd/year)
Age
Gender
1 of 5
17
Select all that apply* This field is required.State required questions
I have been tested for COVID-19 before
This is my first COVID test
I am employed in health care
I have symptoms of COVID
I have been hospitalized
I have been placed in the ICU
I am a resident in a communal (assisted living) care setting
I am pregnant
None of these apply to me
18
Please provide us information on your previous COVID test.* This field is required.State required questions
When was the date of your test? Type in the form of : MM/DD/YYYY
What was the result? Answer Positive or Negative.
19
When was the onset of your symptoms?State mandated feild
Enter onset of symptoms date in MM/DD/YYYY format
Month
Day
Year
20
Signature* This field is required.I authorize Premier Tests, LLC DBA Premier Health TX to send emails, text, and phone correspondence for any lab results following HIPPA regulations. Health information, including labs results, will only be shared with individuals and their guardians. If you authorize another to discuss your medical information please email us at info@premierhealthtx.com.
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