Master COVID-19 Submission Form
Testing location
*
Please Select
Clint Moore Lab 24- Boca FL
Riverside Church- FTL FL
Saint Ambrose- Deerfield Beach FL
St. Vincent Catholic Church- Margate FL
Hallandale Church- Hallandale Beach FL
Global Church- Miami Gardens FL
United Church Fort Lauderdale- FTL FL
Bethel Evangelical Baptist Church- FTL-FL
True Deliverance Church- Miami FL
Visitation Catholic Church- Miami, FL
Royal Palm Christian Church- Coral Springs, FL
Righteous Chapel Church- West Palm Beach, FL
Nativity Lutheran Church & School- Palm Beach, FL
Aloft Orlando Downtown- Orlando, FL
Melia Orlando Celebration- Celebration, FL
Presbyterian Church Of The Lakes- Orlando, FL
Towneplace Suites by Marriott Orlando Southwest Near Universal- Orlando, FL
Southside Church of Christ- Orlando, FL
Primera Iglesia Bautista de Orlando-
Orlando, FL
Grace Church- Schiller Park IL
Immanuel Church- Burbank IL
Main Baptist Church- Aurora IL
Mosaic Comm Church- Joliet IL
Providence Baptist Church- San Fran CA
Test Type
*
PCR
Antigen
Both
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
ID Type
*
Please Select
State ID/License
SSN
No ID
ID Number
*
Do you have insurance?
*
Yes
No
Insurance Provider?
*
Policy # or Member ID
*
Group Number
Insurance Telephone Number
Race
*
Please Select
Caucasian
American Indian or Alaskan Native
Asian
Ancient Mayan
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
Black or African American
Unknown
Ethnicity
*
Please Select
Hispanic
Not Hispanic
Gender
*
Please Select
Male
Female
Undefined
Date of Birth
*
-
Month
-
Day
Year
Date
Patients Relationship to the subscriber
*
First Test?
*
Yes
No
Unknown
Employed in healthcare
*
Yes
No
Unkown
Hospitalized?
*
Yes
No
Unknown
ICU
*
Yes
No
Unknown
Resident in a Congregate Setting (Nursing home, Residential Care, Foster Care)
*
Yes
No
Unknown
Is patient Dependent of Subscriber?
*
Yes
No
Subscriber Name
First Name
Last Name
Subscriber Address (type same if same as above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Subscriber Gender
Male
Female
Prefer not to say
Subscriber Date of Birth
-
Month
-
Day
Year
Date
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