Town of Hamilton and Town of Wenham
2021 COVID-19 Testing
REQUIRED INFORMATION FOR PERSON RECEIVING TEST
One registration form must be completed, in full and must be legible, for each person tested for
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
Town, State Zip Code
Date of birth (MM/DD/YYYY) Age Female Male Other
Person is uninsured
Primary insurance company name
Self (skip section below) Spouse Parent Other
Policy holder last name
ate of birth (MM/DD/YYYY)
Hamilton Resident – 01982 Hamilton Town Employee HWRSD Staff/Student
Wenham Resident – 01984 Wenham Town Employee