COVID-19 Rapid Test PaymentName(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email(Required) Phone(Required)Select Rate(Required)Standard Rate - $80.00Pre-Approved Rate - $60.00Please 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 ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name