HealthX Form

Contact Information

First Name*

Middle Initial

Last Name*

Phone Number*

DOB*

Ethnicity*

Race*

Gender*

Service*

Shipping Address Information

First / Last Name same as above

Shipping First Name*

Shipping Last Name*

Street Address P/O box*

Shipping City*

Shipping State*

Zip Code*

I agree to Xpress's Consent for Service.

I agree to receive monthly COVID-19 tests covered
by my insurance-at zero cost to me.