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300 S. Beverly Drive #100
Beverly Hills, CA 90212
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Insurance, No Insurance and Payment
Please Fill Out The Form Below
Date of Birth
Do you have US insurance?
yes or no
If you have US insurance, Upload front photo of HEALTH INSURANCE CARD. (IF NO INSURANCE, UPLOAD ID card or passport)
Upload photo of health insurance card
Upload supported file (Max 15MB)
NAME OF HOTEL?
Would you like the healthcare professional to come to the hotel?
Yes($250) or No
PCR TEST, RAPID ANTIGEN, NAAT or Rapid PCR. (Rapid PCR is +$500)
PCR, RAPID ANTIGEN OR BOTH
Thanks for submitting!
We have received your information.
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