Vaccination - Registration- TotalWellness

Covid Testing Account Registration

You must create an account before submitting your covid test(s). Your account will allow you to complete your consent form, access your previous test records, and submit any new tests.

* Indicates a required field

Personal Info

Company Code

First Name *

Last Name *

Date of Birth *

Parent/Guardian of a minor under the age of 19 must be present with the minor child the entire vaccination appointment regardless of allergy status.

Phone Number *

Accept Texts *

Sex *

Race *

Ethnicity *

Home Address

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

County

Insurance

Do you have health insurance? *

Insurance Provider

Provider Name *

Member ID *

Group ID *

Primary Insured First Name *

Primary Insured Last Name *

Primary Insured Date of Birth *

Relationship To Primary Insured *

Primary Insured Employer

Card Front

Card Back

Consent

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If participant is a minor or incapacitated adult, please complete the fields below.

Parent/Guardian Full Name:

Parent/Guardian Phone Number:

Account Info

Email Address *

Email Confirmation *

Passwords must be at least 8 characters, have at least one digit ('0'-'9') and at least one uppercase ('A'-'Z').

Password *

Password Confirmation *