Registration Form For COVID Test
Every person getting tested must complete this form
Last name
*
Middle name
First name
*
Date of birth
*
Gender
*
Female
Male
Non-binary
Prefer not to say
Race
*
Asian
Black
Caucasian
Hispanic
N/A
Native American
Non-Hispanic
Other
Phone
*
Email
*
Address Line 1
*
Address Line 2
City
*
State
*
ZIP
*
Location
*
Please select
*Other (Choose this if its not in list)
*Main Location -11475 Olde Cabin Rd
Covid Collection Grande
Covid Collection Hallas Ferry 3
Covid Collection MLK
Covid Collection Site Good Fellow
Paradise Beauty
Alton Urgent Care Walk-In Clinic
Belleville Urgent Care Walk-In Clinic
Granite City Urgent Care Walk-In Clinic
Waterloo Urgent Care Walk-In Clinic
Jeff Wills Inc
Is that test is for travel?
*
Yes
No
Amount paid
*
Due upon specimen collection
Please choose payment method
*
Out of pocket
Uninsured
Insurance
Amount paid
*
Due upon specimen collection
Drivers License Number\ State ID Number
*
Upload Your Driver License or State ID
*
Choose an image file or drag it here.
Reset The Field
Company Name
*
Policy Number
*
Group Number If Available
Upload Your Driver License or State ID
*
Choose an image file or drag it here.
Reset The Field
Upload Insurance Card
*
Choose an image file or drag it here.
Reset The Field
Signature
*
Clear
Submit
Reset
