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PCG Point of Care Molecular Testing

Walk-in appointment intake

Gender

Insurance Information

Insurance Name

Insurance PO Box (on back, if there)

Relationship to primary holder

Policy Number *member ID

Primary Holder

Primary Holder (DOB)

Credit/Debit Card #

Credit/Debit Card #

Credit/Debit Card #

Upload insurance card and Drivers License pictures

Upload (FRONT) insurance card

Upload supported file (Max 15MB)

Upload (BACK) insurance card

Upload supported file (Max 15MB)

Drivers License (FRONT)

Upload supported file (Max 15MB)

Thanks for submitting!

Walk-in appointment intake

Gender

Address (Street, City, State, ZIP)

Insurance Information

Insurance Name

Insurance PO Box (on back, if there)

Relationship to primary holder

Policy Number *member ID

Primary Holder

Primary Holder (DOB)

Self-Pay

Name on card

Credit/Debit Card #

Security Code

ZIP

EXP date:

Choose Test

Upload insurance card and Drivers License pictures

Upload (FRONT) insurance card

Upload supported file (Max 15MB)

Upload (BACK) insurance card

Upload supported file (Max 15MB)

Drivers License (FRONT)

Upload supported file (Max 15MB)

Thanks for submitting!

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Testing purchased by you through PCG Direct is ordered by a licensed healthcare professional authorized to order laboratory testing in accordance with state laws.

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