COVID Registration – Purity Diagnostic

Patient Information

Please fill in the form below

Client ID

PDL110

Last Name *

First Name *

Birth Date *//

Gender *

Ethnicity *

Race *

Sexual Orientation *

Phone Number *

Email Address *

Email

Confirm Email

Address *

Zip Code *

City *

State *

Test Information

Schedule your appointment

Location Center

Main Branch

Available Days Monday to Friday *Walk-in-only
On Saturday *Walk-in-only

Available Days Everyday *Walk-in-only

Available Days Monday to Friday *Walk-in-only
Saturday & Sunday *Walk-in-only

Appointment Date *

Appointment Date & Time *

Date

Time

Reason for testing *

Other for testing *

Do you have insurance *

Yes
No

Insurance

Licence ID / State Photo ID

Government issued ID

Driver's license, state issued non-driver's identification card, or Passport etc.*Please bring your Government issued ID and insurance information with you at the time of your appointment