COVID Tests Request Form
USAMedical LLC - Free Covid-19 Tests, all known variants
Sign in to Google to save your progress. Learn more
Complete your test kit order form below, and our lab will contact you to confirm your needs, and set up your first shipment. We provide complete instructions for administering and returning completed kits. Got Questions? Contact Barbara Drazga, Program Coordinator at 800-674-9490
Organization Name: *
Shipping Address (No P.O. Box): *
Contact Person’s Name & Title: *
Contact Person’s direct phone #: *
Contact Person’s email address: *
Number of people you would like to test (25 tests minimum): *
At how many locations will tests be administered? *
How many times a week would you like to test? *
What days of the week would you like to test?
Do you need nursing assistance? *
If you need a nurse, what TIMES will you be testing on your testing days?
First Kit Delivery Date:
MM
/
DD
/
YYYY
Last Kit Delivery Date:
MM
/
DD
/
YYYY
Your USAMedical Program Rep: *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy