Request GROUP COVID Testing

Name

First Name

Last Name

Company (if applicable)

Minimum Number of Persons to be Tested

Preferred Date of Testing

YYYY

Preferred Time

Hour

Minute

Second

Location of Testing

Where would you prefer to have the testing performed?

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

One Time Testing or Recurrent Testing Needed?

If recurrent, how frequently and for how long?

If your group needs repeat testing, what is the minimum number of testing dates that you will need?

Phone Number

(###)

###

####

Who will pay for this testing?

Will one person pay for the entire group, or will each individual pay for his/her own test?

Test Type Requested

Questions or additional details?

Don’t Wait. Get Tested.

MODERN Mobile Medicine has the resources to safely test you and your employees during the COVID-19 pandemic.

Complete our contact form to receive a quote for testing groups. We offer both PCR and Rapid Antigen (15 minute results) testing.

Individuals and families in need of testing can proceed with Registration for new clients, then Schedule. Do NOT use this form.