Free Covid 19 PCR Testing Intake Form

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Free Covid 19 PCR Testing Intake Form

*Free for those without insurance. No co-pay for those with insurance.

* Indicates required question

Email *

Your email

Name *

Your answer

Age *

Your answer

Date of birth *

MM

/

DD

/

YYYY

Phone number *

Your answer

Email *

Your answer

Insurance Info (if available). Please bring your insurance card to your appointment. *

Your answer

Do you have a valid photo ID? It is not required, but please bring it with you if you have one. *

Yes

No

Preferred appointment time *

Morning

Afternoon

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