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Home
About Us
FAQ
Location
Patient Portal
CAHPS® Performance

Request COVID-19 Testing

Request COVID-19 testing provided by Rapha Family Medicine using this form. It is free for all insured patients including those covered by Medicaid.

For information, call or text 716-200-4122.

Personal Information

Please answer some quick questions about yourself.

Name

Street Address *

Apartment, suite, etc

Zip Code *

Phone Number *

Email Address

Date of Birth *

Month

Day

Year

Medicaid ID

0 / 8

Insurance Type

Insurance #

GenderMaleFemaleOtherPrefer Not to Answer

Testing Location

This is not a mandatory field.

Symptoms

Please answer some questions about how you are feeling.

SymptomsCoughFeverChillsMuscle painSore throatLoss of taste or smellNauseaVomitingDiarrheaTrouble breathingPersistent pain or pressure in the chestChange in mental stateInability to wake or stay awakeBluish lips or facePlease check all which apply.

Please Seek Emergency Medical Attention

According to your selected symptoms, the CDC recommends you seek emergency medical care immediately. Call your primary care provider, local emergency facility, or 911 as soon as possible.

PCP Information

Please enter some information about your Primary Care Provider.

Do you have a primary care provider?Yes, Rapha Family MedicineYes, Main Primary CareYes, otherNo

Provider Name

Phone

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