COVID Rapid Test

4117 Main Street • Whitehall, PA • 18052
P: 610-440-6337 • F: 610-440-6338

CLIA Number: 39D2205057
Medical Director: Rikin Patel
Patient Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Race*
Required By CDC
Ethnicity*
Are You Pregnant?*

YesNoNot Applicable
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email
example@example.com
COST: $50

WE DO NOT ACCEPT INSURANCE FOR THIS TEST
Credit Card Number:*

Exp

Expiration

CVC
Expiration*
CVC*
Appointment*
COVID 19 (SARS CoV 2Rapid Antigen) via Nasal Swab
Result

PositiveNegative
Should be Empty:

Patient Information