Covid-19 Test Order Form Patient Information First Name * Middle Name Last Name Date of Birth Gender Male Female Address Address Address Address City City State Alabama Alaska Arkansas Arizona 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 Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Zip Patient's Telephone * Email * ICD 10 Codes Billing / Insurance Information Bill Patient Bill Client Bill MedicareBill Medicare Bill InsuranceBill Insurance No Insurance Insurance Name & Address Please attach a copy of the card Drop a file here or click to upload Choose File Maximum upload size: 33.55MB Insurance ID Relationship Self Spouse Dependent Tests Covid-19 Antibody Test (Rapid Test) IGG Antibody (SST) IGM Antibody (SST) SARS Covid-19 RT-PCR (with Nasal SWAB Only) Covid-19 PCR (Rapid Test) (With Nasal SWAB Only) Date Requested Time * 07:00 AM - 08:00 AM 08:00 AM - 09:00 AM 09:00 AM - 10:00 AM 10:00 AM - 11:00 AM 11:00 AM - 12:00 PM 12:00 PM - 01:00 PM 01:00 PM - 02:00 PM 02:00 PM - 03:00 PM reCAPTCHA If you are human, leave this field blank. Submit
