COVID Testing Form
Please fill out this form to register before getting your free COVID test.
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First Name *
Last Name *
Email *
Phone Number (xxx) xxx-xxxx *
Sex
Clear selection
Date of Birth
MM
/
DD
/
YYYY
Address
City
State
Zip Code
Which test(s) are you requesting today?
Check all that apply. All tests are free for everyone.
Symptoms (check all that apply)
Do you have an ID?
You may still be tested if you are uninsured or undocumented and all your information is kept strictly confidential.
Clear selection
Do you have health insurance?
You may still be tested if you are uninsured or undocumented and all your information is kept strictly confidential.
Clear selection
Plan Name
Please be specific (i.e. Amerigroup - Community Care). Put n/a if not insured.
Member/Subscriber/Policy ID
N/a if not insured
By checking this box, you are authorizing this provider to administer COVID testing at this site and retain a copy of your ID and insurance card if you have them for records. You will not receive a bill from us as our services are completely free to all!
Results of the rapid test will be given directly 20 minutes after swabbing or via email if requested and PCR results will be available through a patient portal. Average turn around time for PCR test is currently 2-3 days. Positive results should continue to quarantine until 5 days after onset of symptoms or positive test result. If symptoms persist beyond 2 weeks, seek medical attention as you may have a secondary infection. You should seek emergency services if you develop severe symptoms such as shortness of breath to the point of being unable to speak full sentences, persistent chest pain, inability to wake, new confusion, or blue or gray lips/nails.
By typing my name below, I certify that all the information I have provided is true and accurate.
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