WELCOME TO EVERPOINT

PCR Test Collection

Wedding

Kindly complete the form below and upload your PCR test results. .

PLEASE DO NOT RE-SUBMIT. Once submitted, you will receive an email confirmation. If you do not see the e-mail, kindly check spam.

If you have any trouble, please contact Erica at etripodi@everpointhealth.com or 203-517-7687.

This form is secure and HIPAA-compliant .

Guest Information

Personal Information:

First Name of Guest:

Last Name of Guest:

Date of Birth of Guest:

PCR Test Result Upload

PCR Test Result:

Upload File

Patient Consent

By checking the general consent box below, I certify that I am either (1) at least 18 years of age or (2) I am legally recognized as an ‘emancipated minor’ by the state in which I reside or (3) I am the parent or legal guardian of the minor on behalf of whom the test result is provided.

I hereby authorize Everpoint Medical, PLLC / Everpoint Health, LLC to disclose this information to my event host. The purpose of this disclosure is to provide information to the above listed individual/entity for infectious disease management. I understand that I may refuse to sign this authorization.

I accept the above conditions.

Your submission was successful!