Order Form – Touch Heal Care

Touch Heal Care

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Find Location
FAQ
Product

Patient Information

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How did you hear about us *

Name *

First

Last

Date of Birth *

Gender *

Are you Pregnant? *

Do you have a lab order from a doctor? *

Yes
No

Choose desired level of testing:

Essential - like a good primary care doctor
Full - like a top academic specialist doctor
Advanced - best tests available to science

What is your race?

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Unknown / choose not to provide

Ethnicity?

Hispanic
Non-Hispanic
Unknown / choose not to provide

Reason for Visit: *

Who is Visiting:

Phone *

Layout

Email *

Email

Confirm Email

[email protected]

Preferred Method Of Contact: *

Phone
Email

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Insurance Information

Covid-19 rapid tests are covered by most insurance companies at no out-of-pocket cost for insured patients. You can elect to receive up to 8 at-home rapid tests.

Do you have Health Insurance ? *

Insurance Name: *

Please upload front side of your insurance card *

Click or drag a file to this area to upload.

Please upload back side of insurance card *

Click or drag a file to this area to upload.

Provide Social Security Number *

How often would you like to receive the test? *

Date of Test *

Please upload ID

Click or drag a file to this area to upload.

Terms & Conditions