EmailMe Form - COVID-19 Testing Registration Form

If you need an immediate test or this is for symptoms or physician referral please call 888-BMC-LINK
Name *
First Last
Date of Birth *
MM / DD / YYYY
Gender *
Race *
Ethnicity *
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Home Phone
### - ### - ####
Email
This email will be used to notify you of test result

Confirm
Cell Phone *
### - ### - ####
Reason for testing
Travel
Employment
School
Other
Other Reason for Testing
Payment Details
Please provide payment details below
Authorized Amount *
COVID-19 PCR Test $ 85.00
By checking this box you are acknowledging that you are agreeing to pay $ 85.00 charge for your COVID test and authorizing us to charge your credit card for your test.
You also understand this is not being submitted to insurance by our company and that you are solely responsible for this payment.
Credit Card

Card Number

Credit card data securely collected in accordance with global PCI standards. Sensitive data is encrypted and stored in our Secure Form Vault.

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.
Authorization of Charges *
I do authorize
As named Cardholder; I Authorize: County Ambulance Service to immediately charge my credit card the above amount, to complete the reservation of my COVID test.