COVID-19 TEST REQUISITION FORM

Please fill in details below!

Patient Name*

Email*

Biological Sex *

Date of Birth (MM/DD/YYYY)*

Phone Number

Address*

City, State& Zip Code*

Primary Insurance*

Primary Insurance ID#*

For non-insured patient: SSN or State ID is required

Please attach copy of your ID

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For the paper form, please download & fill the form below a

Req-form COVID-19 (pdf)Download

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Name

Email*

Phone*

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Walk- in Available: You can also visit us at:

Danville Office: 109 Deer Run Rd, Danville, VA 24540.
Fairfax Office: 3927 Old Lee Hwy, Unit 102-D, Fairfax, VA 22030
Greensboro Office: 1451 South Elm-Eugene St, Greensboro, NC 27406.
* Please call first for availability

Accurate Medical Laboratories

(855) 571-1733

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Covid19 Test

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We offer COVID-19 Test Now!