BioCentra Diagnostics, A state of art medical laboratory for all your needs

Location

First name*

Middle name

Last Name*

Email*

Gender*

Date of Birth*

Mobile Phone*

Address*

City*

State*

Zip*

Driver’s License/SSN/Passport Number*

Driver’s License/SSN/Passport*

*Upload image

Health Insurance*

Insurance Company*

Member ID*

Group Number*

Insurance card front side*

*Upload insurance card front image

Insurance card back side*

*Upload insurance card back image

Others

Appointment Date*

Available Times*

Patient Signature*

Date*

COVID-19 Rapid Antigen Test