Lets collect some information about you.

First Name
Middle Name
Last Name
Gender
Marital Status

We will need some contact information from you about .

Email Address
Street Address
City
State
Zip
Mobile Phone
Home Phone
Alternate Phone Number
  Uncheck this box if you CAN NOT receive text messages.
Uncheck this box if you DO NOT consent to having your records sent electronically to you.

We will need to collect identifying information for your medical records

Social Security Number
Drivers License No.
License State:
Date Of Birth //
Ethnicity

These general questions will help us serve you better.

Is a resident of the following cities
Is Demonstrating Symptoms?
Did have any of the following exposures?
Is an employee of the following?
Where did hear about us?
What county does live in?
What 's your primary language?

Insurance information for

Does have health insurance? Yes, No
SNAP A PICTURE
FRONT of Insurance Card

Please click the button below and take a picture of THE FRONT of your insurance ID using your camera.
Primary Insurance Company
Policy #
Group No
Name Of Primary Insured
What is your relationship to
Secondary Insurance Company optional
Secondary Policy #
Secondary Group No. optional
Secondary Name Of Primary Insured optional
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BACK of Insurance Card
Please click the button below and take a picture of THE BACK of your insurance ID using your camera.
You have been granted temporary, limited Medi-Cal coverage effective today under the Presumptive Eligibility for Coronavirus (COVID-19) Diagnostic Testing and Treatment Services Only program. Under this program, diagnostic testing, testing-related services, and treatment services for COVID-19, including the associated office, clinic, or emergency room visit, are covered at no cost. Use this Confirmation Document to get your COVID-19 diagnostic testing, testing related services, and treatment services, including all medically necessary care. Your eligibility will end on the last calendar day of the month in which the 60th day falls from the date of your PE application.

We're almost done! This is the final information we need from you for

SNAP A PICTURE
FRONT of 's drivers license

Please click the button below and take a picture of 's drivers license using your camera.
Appointment Date
Appointment Time
//:

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Electronic Signature
Type 's name above, as your electronic signature to accept our terms of use and schedule your appointment.
I, declare under penalty of perjury that I have truthfully completed this application for COVID-19 testing including my insurance status and the patient consent information found here:

click here to view the disclosure