Wake Toxicology Laboratory
Durham: 5129 NC-55, Ste 103-104, Durham, NC 27713
Wilmington: 3326 Jaeckle Dr, Ste 110, Wilmington, NC 28403

COVID-19 Test Request Form (Molecular RT-PCR Test)
Email address *
First Name *
Last Name *
Date of Birth *
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Gender
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Address *
Mobile Number
Insurance Name
Insurance ID
No Insurance? Provide State ID or Driver License
Race/Ethnicity
Appointment Date And Time
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Time
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COVID Symptoms
A copy of your responses will be emailed to the address you provided.
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