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Milart Pharmacy
300 S. Beverly Drive #100
Beverly Hills, CA 90212
rx@milartrx.com
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Friends Club COVID Testing
Insurance, No Insurance and Payment
Please Fill Out The Form Below
PCR TEST, RAPID ANTIGEN OR BOTH
PCR, RAPID ANTIGEN OR BOTH
First Name
Last Name
Date of Birth
Address
Do you have insurance? In the next section: If Yes, Upload your insurance card. If NO, upload your ID.
yes or no
If you have US Insurance, Upload photo of the front of insurance card. If you do not have US insurance, upload photo of your ID.
Upload photo of health insurance card or ID
Upload supported file (Max 15MB)
DATE for the Test?
TIME for the Test?
NAME OF LOCATION
Submit
Thanks for submitting!
We have received your information.
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