Please provide us the following information to schedule your appointment. These test are covered by most insurances. Step 1 of 2 50% Name* First Last Email* Mobile Phone*DOB*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address (Include Apt #)*City*State*ZIP*Sex*Please SelectFemaleMaleOtherMarital Status*Please SelectSingleMarriedDivorcedPreferred Language*Please SelectEnglishSpanishOtherEthnicity*Please SelectNative AmericanHispanic or LatinoNot Hispanic or LatinoOtherHow did you hear about us:*Newsletter Consent I accept to receive newsletters from Formé Type of Exam*Covid-19 Rapid Test - $110 Covid-19 Pcr Test - $25 Do you have insurance?*Please SelectYesNoInsurance Name*Please Select1199 Local BenefitAARP completeAetnaAffinityBluBlue Cross and Blue ShieldBluBlue Cross Blue Shield MediblueCignaHIPEmpire planFidelisHealthFirstMedicaidMedicareMeritain HealthMultiplanMVPOxfordUMRTricareUnited HealthcareOtherMember ID*Enter Insurance Name*Type of Payment*Please SelectPaypalCashAppointment date* January 2021 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 January 27, 2021 11:15 AM 11:30 AM 11:45 AM 12:00 PM 12:15 PM 12:30 PM 12:45 PM 1:00 PM 1:15 PM 1:30 PM 1:45 PM 2:00 PM 2:15 PM 2:30 PM 2:45 PM 3:00 PM 3:15 PM 3:30 PM 3:45 PM 4:00 PM 4:15 PM 4:30 PM 4:45 PM 5:00 PM 5:15 PM 5:30 PM January 28, 2021 8:15 AM 8:30 AM 8:45 AM 9:00 AM 9:15 AM 9:30 AM 9:45 AM 10:00 AM 10:15 AM 10:30 AM 10:45 AM 11:00 AM 11:15 AM 11:30 AM 11:45 AM 12:15 PM 12:30 PM 12:45 PM 1:00 PM 1:15 PM 1:30 PM 1:45 PM 2:00 PM 2:15 PM 2:30 PM 2:45 PM 3:00 PM 3:15 PM 3:30 PM 4:00 PM 4:15 PM 4:30 PM 4:45 PM January 29, 2021 8:15 AM 8:30 AM 8:45 AM 9:15 AM 9:30 AM 9:45 AM 10:00 AM 10:15 AM 10:30 AM 10:45 AM 11:00 AM 11:15 AM 11:30 AM 11:45 AM 12:00 PM 12:15 PM 12:30 PM 12:45 PM 1:00 PM 1:15 PM 1:30 PM 1:45 PM 2:00 PM 2:15 PM 2:30 PM 2:45 PM 3:00 PM 3:15 PM 3:30 PM 3:45 PM 4:00 PM 4:15 PM 4:30 PM 4:45 PM January 30, 2021 9:00 AM 9:15 AM 9:30 AM 9:45 AM 10:00 AM 10:15 AM 10:30 AM 10:45 AM 11:00 AM 11:15 AM 11:30 AM 11:45 AM 12:15 PM 12:30 PM 12:45 PM January 31, 2021 9:00 AM 9:15 AM 9:30 AM 9:45 AM 10:00 AM 10:15 AM 10:30 AM 10:45 AM 11:00 AM 11:15 AM 11:30 AM 11:45 AM 12:15 PM 12:30 PM 12:45 PM Briefly describe your symptoms:*ATTENTION PATIENTSAccording to the Executive Order signed by Governor Andrew M. Cuomo on September 9th, 2020, effective immediately healthcare providers who order or administer molecular, antigen or serological test for COVID-19 are to report the following patient information to the Department of Health. The following information MUST be submitted to receive your COVID test:Name*Ethnicity*Please SelectNative AmericanHispanic or LatinoNot Hispanic or LatinoOtherOcupation*Please SelectEmployeeStudentEmployer name*Employer address*Employer phone*Name of school/college/university*School’s address*School’s phone*PhoneThis field is for validation purposes and should be left unchanged.
