EmailMe Form - COVID-19 Test Registration

Name *

First Last

Date of Birth *

MM / DD / YYYY

Gender *

Race *

Ethnicity *

Home Address (no PO Boxes) *

Apt/Building/Suite etc

City/Town *

State *

Zip Code *

Primary Phone *

### - ### - ####

Secondary Phone (if any)

### - ### - ####

Email

This email will be used to notify you of test result

Confirm

Book Your Time Slot

Vehicle Information

In order to facilitate a faster testing experience please share you vehicle information that you will be arriving in.

Vehicle Make

Vehicle Model

Vehicle Color

Plate Number if known

Payment Authorization

Credit Card

Card Number

Protected in vault Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault.

I hereby authorize County Ambulance to bill my credit/debit card $ 115 for COVID testing.
Yes to authorize