Omnicare Medical Center PCR Registration Form

"*" indicates required fields

Unique ID

Hidden

Order ID

Date*

Time*

Email*

Enter Email (Case Sensitive) Confirm Email (Case Sensitive)

Phone*

Address on Island.*

Street Address Address Line 2 City State / Province / Region Country

Name*

First Middle Last

Date of Birth*

Sex*

Male

Female

Nationality*

ID Number*

ID Type*

Passport

Driver's licence

National ID

NHIP

Please upload a copy of your ID.*

Max. file size: 2 GB.

Workplace*

Occupation*

Symptoms being experienced?*

Reason for Testing?*

Hidden

Test Results