LEVELUP COVID TESTING DRIVE REGISTRATION- 144 BOERUM STREET, BROOKLYN NY
Name (Patients Name)
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First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Which Test are you here for today? (select 1 or 2)
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PCR TEST (Covid 19)
RAPID ANTIGEN TEST (Covid 19)
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
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If you don't have an email, please put "example@example.com"
Email Address
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example@example.com
Phone Number
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Gender
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Female
Male
Non-Binary
Do Not Wish to Disclose
Do you have Medical Insurance?
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Yes (Enter information below)
No (Enter Social Security Number Below)
Social Security (Only if you DO NOT carry Medical Insurance)
Insurance Carrier
Member ID
Upload Photo ID (or Parents Id if Patient is under 18 y/o)
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of
Upload front of Insurance Card
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By signing below, I am consenting to have myself/my child tested for Covid19 by Levelup Urgentcare @ Boerum Street Location
By Signing Below, you understand that Levelup MD Urgentcare will not charge you for this test but may bill your health insurance/coverage. By entering my information, I understand that Levelup MD Urgentcare will share the information on this form and my test results with the State of New York and their designees so that they can seek reimbursement. I authorize benefits to be payable to Levelup MD UC.
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