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Milart Pharmacy
300 S. Beverly Drive #100
Beverly Hills, CA 90212
rx@milartrx.com
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Private Party COVID Testing
Insured and Uninsured
(PCR and Antigen)
Please Fill Out The Form Below
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
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NAME OF PARTY or HOST?
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