Legal First name of person being tested:*

Last Name:*

Date of Birth:*
MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day01020304050607080910111213141516171819202122232425262728293031 Year202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901

Gender:*
Male      Female      Other

Race:* Select RaceWhiteBlackAsianHispanicOtherPrefer not to answer

Ethnicity:* Select EthnicityHispanicNot HispanicUnknownPrefer not to answer

Address as it is listed with the insurance:*

Street:*

City:*

State:*

Zip:*

Email:*

Email Confirmation:*

Phone:*

Test Requested:*
Covid-19 Rapid (1-2 hours)
Covid-19 PCR (48-96 hours)
Covid-19 Rapid & Flu (1-2 hours)

Symptoms:*

Are you having difficulty breathing?*     Yes      No

Are you having shortness of breath?*     Yes      No

Do you have any signs or symptoms of Covid?*     Yes      No

Insurance Carrier:

Insurance Plan ID:

Insurance Card:

Upload Front of Insurance Card:

Upload Back of Insurance Card:

Upload Drivers License/Non-Driver ID Card:*
I don't have an ID

Signature: * Clear Signature