• COVID-19 Rapid Testing Registration Form

    (For patients billing insurance)

  • In order to utilize your insurance for billing for the rapid COVID test, you will be required to attend a brief office visit with a provider and fill out a few more documents. These documents will be sent to you by our CMA after your registration is complete.

  •  -  - Pick a Date
  •  -  - Pick a Date

  • Detailed Demographic Information

    The following information is optional, however, it does help us apply for an obtain grants to better serve our community.

  • Emergency Contact

    We must legally have an emergency contact to reach out to in the case of risk of harm to you or others.

  • Insurance Information

    We bill insurance as a courtesy. If you are self pay, all charges are due at time of visit unless arrangements are made ahead of time with the Clinic Director.
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  •  -  - Pick a Date
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  • Driver's License

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  • Patient Preferences

    Please indicate your preferences for the following (if you don't have a preference, you may leave blank).
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