COVID Booking

COVID-19 Booking

"*" indicates required fields

For How Many People?

Testing Purpose*

Name*

First Last

Date of Birth*

Name of Person 2*

First Last

Date of Birth of Person 2*

Name of Person 3*

First Last

Date of Birth of Person 3*

Name of Person 4*

First Last

Date of Birth of Person 4*

Name of Person 5*

First Last

Date of Birth of Person 5*

Name of Person 6*

First Last

Date of Birth of Person 6*

Name of Person 7*

First Last

Date of Birth of Person 7*

Name of Person 8*

First Last

Date of Birth of Person 8*

Name of Person 9*

First Last

Date of Birth of Person 9*

Name of Person 10*

First Last

Date of Birth of Person 10*

Email*

Enter Email Confirm Email

Phone*

Appointment Location*

Street Address Address Line 2 City State ZIP Code

Appointment Date & Time*

May 2024

Sun	Mon	Tue	Wed	Thu	Fri	Sat
			1	2	3	4
5	6	7	8	9	10	11
12	13	14	15	16	17	18
19	20	21	22	23	24	25
26	27	28	29	30	31

You can book 2 or more people with the same time slot

COVID Test Type*

COVID Test Type for Person 2*

COVID Test Type for Person 3*

COVID Test Type for Person 4*

COVID Test Type for Person 5*

COVID Test Type for Person 6*

COVID Test Type for Person 7*

COVID Test Type for Person 8*

COVID Test Type for Person 9*

COVID Test Type for Person 10*

Subtotal

$0.00

Group Discount (10% off for 5 or more)

$0.00

Service Tip (Optional)

Total Cost

Credit Card

Cardholder Name

Card Details

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COVID-19 Booking

May 2024

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