COVID19 vaccination form

Request for COVID-19 testing

COVID-19 testing is covered by either your insurances or the government non-insured funds. In most cases, there is no out of pocket cost to patients. Once the form is completed and submitted, our staff will contact you to schedule an appointment.
Patient name *
First name Middle initial Last name
Date of Birth *

Day Month Year
Age *
Gender *

Male Female
Race *
Mobile Number *

Area Code Phone Number
E-mail Address *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Have you been seen as a patient at our facilities *

Yes No
Reason for testing
COVID-19 test requested: *

Rapid test (results generally available within 1 to 2 hours) PCR test (results turn around time is about 2 days)
I have questions and I am requesting for a televisit with a provider prior to COVID-19 testing.
Authorization & Consent For Treatment - Please complete, save a copy to your desktop or phone, then upload below.
Upload Authorization & Consent For Treatment

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Cancel of
Upload an image of your driver license or ID card *

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Cancel of
Upload the front image of your Medicare or insurance card *

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Your Medicare or insurance carrier may be billed for any fee associated with COVID-19 vaccination such as televisit, counseling, administration, and treatment of anaphylactic reaction. There is no charge directly to patients for the COVID-19 vaccination and you will not be billed for any balances for the above services. There is also no out of pocket cost for uninsured patients. Cancel of
Upload the back image of your insurance card *

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Cancel of
Insurance subscriber name & DOB if it is not you.
I am uninsured
Financial policy
HIPAA / Privacy policy
Should be Empty:

Request for COVID-19 testing