Client Intake Form
Are you interested in FREE COVID TESTING? Fill out this form below and we will get back to you within 24 hours.
Client Organization/Company Name
*
Phone Number
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Email Address
*
Address
*
Street Address
Street Address Line 2
City
Please Select
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South Carolina
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Tennessee
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West Virginia
Wisconsin
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State
Zip Code
Desired Testing Start Date
*
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Month
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Day
Year
Date
Category/Industry
(School, Club, Organization, Event Space, etc)
Number of Locations That Require Testing
Will Testing Be Weekly or Multiple Times a Week?
*
Weekly
Multiple Times a Week
Will Testing Be Voluntary or Mandatory?
*
Voluntary
Mandatory
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Location Information
Location Name
Shipping Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Contact Name
First Name
Last Name
Weekly or Multiple Times a Week?
Weekly
Multiple Screenings a Week
Number of Test Kits required weekly?
Best Days for Delivery (Select one or more)
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Best Days for Pickup (Select one or more)
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Please enter additional locations as needed:
*
Name of Ravinia Health Executive
*
First Name
Last Name
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