113 W Sycamore Street, Attica, IN 47918 (877) 339-9567 (765) 762-3035

Application for Testing

Name of Contact*
First Last
Contact Phone*
Contact Email*
Name of ILL Person*
First Last
Address of ILL Person*
Street Address Address Line 2 City State ZIP Code
Age of ILL Person?*
Please enter a number from 1 to 99.
How Many Days Sick?*
Please enter a number from 1 to 99.
Fever over 100.5?*
- Yes
- No
Cough?*
- Yes
- No
Suspected COVID-19 Contact?*
- Yes
- No
I have insurance*
- Yes
- No
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