Covid | AmeriMed

Covid OTC Test Order Form

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First Name

Date of Birth

Last Name

Gender

Mobile Phone

Address

Are you the Primary Insured?

Relationship to Primary Insured?

Primary Insured

Insurance Carrier

Cardholder ID

Verify Cardholder ID

BIN

Group

PCN

(Optional) Upload Photo of Insurance Card

Upload File

Do you have additional Family members you like to order test for?

Yes

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Gender

Does your spouse have the same address?

Spouses Address

Child 1 First Name

Child 1 Date of Birth

Child 1 Last Name

Gender

Does child 1 have the same address?

Child 1 Address

Child 2 First Name

Child 2 Last Name

Child 2 Date of Birth

Gender

Does child 2 have the same address?

Child 2 Address

Child 3 First Name

Child 3 Last Name

Child 3 Date of Birth

Gender

Does child 3 have the same address?

Child 3 Address

Child 4 First Name

Child 4 Last Name

Child 4 Date of Birth

Gender

Does child 4 have the same address?

Child 4 Address

Covid OTC Test Order Form

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3782 OLD U.S. 41 N, VALDOSTA, GA 31602