NOW ACCEPTING HEALTH INSURANCE

No Out Of Pocket Costs With Health Insurance

In Order To Pay For Coronavirus (Covid-19) Testing By Using Your Health Insurance Please Fill Out The Form Below. Please Answer All Questions Truthfully.

Date of birth
Special instructions for minors
Age 10-15: Parent or legal guardian needs to fill out form and accompany patient to visit.
Age 16-17: Parent or legal guardian needs to fill out form.

Patient date of birth
Select a date
Field is required!
Field is required!
Have you experienced any of these symptoms?
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Field is required!
If you answered yes to the above question.
(Select any that apply)
Field is required!
Field is required!
Approximately what date did your symptoms begin?
Select a date
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Field is required!
Do you have any of the following medical conditions?
Field is required!
Field is required!
If you answered yes to the above question.
(Select any that apply)
Field is required!
Field is required!
If applicable, are you currently pregnant?
Field is required!
Field is required!
Do you work in health care?
Field is required!
Field is required!
In the past 14 days, have you had known or suspected exposure to the SARS-CoV-2 virus or a COVID-19 patient?
(e.g. been exposed to someone with COVID-19 or been in a large public gathering where exposure is suspected)
Field is required!
Field is required!
Do you work in a special setting where the risk of COVID-19 transmission may be high?
(This may include long-term care, correctional and detention facilities; homeless shelters; assisted-living facilities and group homes.)
Field is required!
Field is required!
Are you a resident in a special setting where the risk of COVID-19 transmission may be high?
(This may include long-term care, correctional and detention facilities; homeless shelters; assisted-living facilities and group homes.)
Field is required!
Field is required!
Have you been prioritized for testing by a medical professional?
Field is required!
Field is required!
Is this your first time taking the COVID-19 test?
Field is required!
Field is required!
Please Upload Image Of Driver's License:
*images can be a JPG, PDF, GIF, or PNG - max files size of 5 MB
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Please Upload Image Of Front Of Health Insurance Card:
*images can be a JPG, PDF, GIF, or PNG - max files size of 5 MB
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Please Upload Image Of Back Of Health Insurance Card:
*images can be a JPG, PDF, GIF, or PNG - max files size of 5 MB
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Field is required!
Field is required!
Field is required!