Community/School (non-sports) - Test Site Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please fill this form out to set up Mobile PCR COVID testing (self administered saliva test) at your Community Site.

Please only fill ONE form for ALL testing dates.

Once form is submitted, changes cannot be made. Please email us for any changes.

If you are NOT signing up for a Community Test Site and need testing for a Sports Team, please email us for the correct Google Form.

Contact us at COVID@GreenMCM.com with any questions prior to signing up.

Email *

Name of Organization *

First and Last Name *

Cell Phone *

Name and shipping address for supplies *

Anticipated start date? *

YYYY

Will this be a reoccurring test site? *

Yes

Is testing mandatory or optional for patients? *

Mandatory

Optional

Other:

Is testing mandated for vaccinated patients? *

Yes

Number of patients testing per day? *

Do you have a medical professional associated with your organization? If yes, what license do they hold? *

Question or Comments

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms