Town of Hamilton and Town of Wenham
2021 COVID-19 Testing
Registration Form
REQUIRED INFORMATION FOR PERSON RECEIVING TEST
One registration form must be completed, in full and must be legible, for each person tested for
COVID-19.
It is important to provide your insurance information so that tests can be processed appropriately.
If you are uninsured, you will not be charged for this test.
By signing below, I am stating that I am having symptoms of
COVID or am a close contact of a COVID positive person.
Last name Middle name First name
Street Address
Town, State Zip Code
Date of birth (MM/DD/YYYY) Age Female Male Other
Email Address
I
NSURANCE INFORMATION
Person is uninsured
Primary insurance company name
Insurance ID#
P
olicy holder
Self (skip section below) Spouse Parent Other
Policy holder last name
First name
D
ate of birth (MM/DD/YYYY)
Hamilton Resident – 01982 Hamilton Town Employee HWRSD Staff/Student
Wenham Resident – 01984 Wenham Town Employee
