info@covid19testingfree.com
(336) 580-1466
Home
Testing
Schools Testing
Corporation Testing
Individual Testing
Service Areas
FAQ
Blog
Contact Us
USD
(336) 580-1466
info@covid19testingfree.com
USD
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.
Form Introductory Text
Name (Last, First, Middle Initial)
*
Date of Birth
Gender (M or F)
*
Male
Female
Address (Street, City, State, ZIP)
Cell Phone
*
✓ Valid
Email address
*
Bill to (Medicare, Medicaid, Insurance Name, No insurance)
Insurance ID #
Testing location
Date you plan on coming to this site
Submit
Top
Home
Testing
Testing
Schools Testing
Corporation Testing
Individual Testing
Service Areas
FAQ
Blog
Contact Us
Top