• REQUIRED INFORMATION FOR PERSON RECEIVING TEST

    • One registration form must be completed in full, for each person being tested for COVID-19.
    • A new form is required for any repeated testing, as applicable. It is important to provide your insurance information
      so that tests can be processed appropriately.

  • Insurance Information

  • Patient Consent Authorization

  • Clear
  • FOR OFFICE USE ONLY

  • Should be Empty: