Registration Form

This form is for pre-registering for a drive-thru or walk up site. This will help expedite your testing at the location you are attending.

Name (Last, First, Middle Initial)*

Date of Birth

Gender (M or F)*

Male Female

Address (Street, City, State, ZIP)

Cell Phone*

Email address*

Bill to (Medicare, Medicaid, Insurance Name, No insurance)

Insurance ID #

Testing location

Date you plan on coming to this site

Submit