Quick Unsupervised COVID-19 Patient Order

COVID-19 Patient Form

Authenticate your order by filling in your order information.
Name *

First Name Last Name
Email *
example@example.com
COVID-19 Medical Questionnaire. Do you have any of the following? Please check any item that applies. *

Fever or Chills Cough Shortness of Breath Fatigue Muscle or Body Aches Headaches New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea Exposed to suspected COVID-19 Live in place COVID-19 is high Contact with COVID-19 person
Shipping Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

My Products *

COVID-19 PCR Test $ 99.00

Standard shipping included

Quantity

COVID-19 PCR Test (Expedited Shipping) $ 149.00

Overnight shipping included

Quantity

COVID-19 PCR Test (Expedited Processing + Shipping) $ 249.00

Includes overnight shipping and expedited lab procesing

Quantity

Enter coupon

Total $ 0.00

COVID-19 Patient Form