Submit your COVID Test information today. Date of Birth* Gender*---MaleFemale Ethnicity*---AfricanAshkenazi JewishCaucasianEuropean (Finnish)East AsianNear/Middle EasternLatinoSouth AsianOther StateALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Insurance Information*InsuredNon-Insured Relation to Policy Holder*SelfSpouseChildOther D.O.B. of policy holder* Photo ID or Passport style photo (jpg or png only)* I acknowledge that I have answered the above questions to the best of my knowledge. I understand that if I have insurance, I must provide all insurance information to MDL. I authorize My Doctors Live, LLC to conduct testing via oral/nasal swab for detection of SAR-CoV-2 as ordered by my physician, authorized healthcare provider or for self diagnoses.
