STANDARD COVID-19 TESTING

CALL
(855)630-SWAB (7922)

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Phone*
Date of Birth*
Race*
Ethnicity*
3. Medical Information

Are you an existing patient of one of the following medical practices:*
- Florida Pain Relief Group
- Pain Relief Centers
- Not an existing patient of either
Payment Type*
- Insurance
- Self Pay
Name of Insurance Carrier*
Insurance Member ID*
Insurance Group Number (if applicable)
Insurer's Phone Number*
This can usually be found on the back of your insurance card
4. Finalize

I understand that by submitting the above personal as well as health insurance information, I consent to information about my testing and results being shared with the health insurer or government agency paying for my testing for purposes of payment, treatment, and/or health operations and as otherwise described in our privacy policy*
I give my consent
I understand that by submitting the above personal as well as health insurance information, I consent to information about my testing and results being shared with the health insurer or government agency paying for my testing for purposes of payment, treatment, and/or health operations and as otherwise described in our privacy policy