Fillable 2021 COVID-19 Testing Registration Form Self Pay (Town of Hamilton)

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2021 COVID-19 Testing Registration Form Self Pay (Town of Hamilton)

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The 2021 COVID-19 Testing Registration Form Self Pay (Town of Hamilton) form is 1 page long and contains:

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File type: PDF

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Town of Hamilton and Town of Wenham
2021 COVID-19 Testing
Registration Form – Self Pay
REQUIRED INFORMATION FOR EACH PERSON RECEIVING TEST
One registration form must be completed, in full and must be legible, for each person tested for COVID-19.
This form to be used if testing for non-medical needs (travel or peace of mind).
$85.00 will be charged per test by Beauport Ambulance Service, Inc.
Last Name Middle Name First Name
Street Address
Town, State Zip Code
Date of Birth (MM/DD/YYYY) Age Female Male Other
Email Address
CREDIT CARD INFORMATION (VISA OR MASTERCARD ONLY) – NO CHECKS OR CASH
Visa Mastercard
Credit Card Number CVC (on back of card)
Name on Card
Expiration Date (MM/YYYY)
Phone
Cell
Home
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2021 COVID-19 Testing Registration Form Self Pay (Town of Hamilton)

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Completed 17 February 2021

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