Brick COVID-19 Test Registration

There is no cost to you for this test, all medical insurance fully covers the cost. You may also receive a statement from your insurance company - an explanation of Benefits (EOB) - which will itemize the services received, but it is not a bill and there is nothing to pay even if a balance is indicated.

Please note that all participants are required to arrive at the designated test location wearing a mask during your scheduled date. All information is confidential under strict HIPAA guidelines.

Location:

Date and Time: (Please select an open time)

First Name:

Last Name:

Date of Birth:

Gender:

Male

Female

Address:

City:

State:

Zip Code:

Mobile Phone:

Email: (Optional but recommended)

Primary Insurance:

Subscriber ID:

Group Reference:

Secondary Insurance: (Optional, if covered)

Subscriber ID:

Group Reference:

Primary Physician: (Optional)

Physician Phone: (Optional)

Please let us know the following to help prioritize your test -

Current Symptoms:

Current Medical History:

Asthma or chronic lung disease
Cancer (current or previous)
Cirrhosis of the liver

Diabetes
Diseases that make it hard to cough
Kidney failure or ESRD

Obesity (BMI over 30)
Serious heart condition
Weakened immune system

Additional Questions:

I have been exposed to someone who tested positive

I have been prioritized for testing by a medical professional

I work in health care or work/live a setting where the risk of COVID-19 transmission is high

Acknowledgement and Authorization to Test:

I acknowledge that I have answered these questions truthfully to the best of my knowledge.

I further provide consent for testing, including as a parent or legal guardian to minors that I may have registered.

You must acknowledge and authorize in order to submit this form.

Brick COVID-19 Test Registration

Registration Confirmed

Cancellation Confirmation

Registration Cancelled

Duplicate Registration Found