Covid-19 Test
Patient Registration Form

Patient Information

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***We only accept Medicare and BCBS for non-established patients

Please upload image of your Driver's License and Insurance Card

Upload Driver's License
Please upload a picture of your Insurance Card
Upload Insurance Card
Only Medicare and BCBS

Clinical Information

Reason for Testing

Symptoms Questionnaire - please select all tht apply
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Have you been diagnosed with any of the following underlying conditions?

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