JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Testing Appointment - Watauga County
126 Poplar Grove Connector, Boone, NC 28607
Your information is private and secure when sent to this site. It utilizes 256-bit Transport Layer Security (TLS).
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Please be aware that you will receive an email confirmation with your appointment time and testing information upon submission of this form. If you do not have an email address please call us at 828-795-1970 to make an appointment.
*
I consent to receiving an email confirmation of my appointment
Required
Appointment Day
*
Choose
This appointment time is full, please select another.
Monday 6/21
First Name
*
Legal Name
Your answer
Last Name
*
Your answer
Sex Assigned at Birth
*
Male
Female
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
*
Example: 8282644995 (Please do not include dashses or any other symbol, simply type the number)
Your answer
Mailing Address (inlcude zip code)
*
Your answer
Insurance Type
*
Currently, COVID-19 testing is offered at no charge. You will not be billed for your COVID-19 test and you will not be charged a copay.
Uninsured
Blue Cross Blue Shield
United Healthcare
Medicare
Medicaid
Tricare/Champus
Other:
Insurance Card Number
*
This will be your subscriber or member ID. Type "N/A" if you are uninsured.
Your answer
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of AppHealthCare - Appalachian Partners in Public Health.
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report