COVID-19 Rapid Test Payment

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email(Required)

Phone(Required)

Select Rate(Required)

Please select the Standard Rate above unless you have already made arrangements with Horizon Health and Wellness for the Pre-Approved Rage. Failure to select the correct rate may prevent you from being tested at your selected appointment time.

Quantity(Required)

Payment ID(Required)

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name