Appointments Request Form

New COVID-19 Test Appointment Request:

First Name

Last Name

Month (of Birth):

Day (of Birth):

Year (of Birth):

Phone Number:

Email:

COVID-19 Test Reason for Visit:

COVID-19 Rapid PCR/NAAT $150 or Rapid Antigen $75 for any INTERNATIONAL TRAVEL, EMPLOYMENT, or PRIVATE EVENT

Preferred Test Appointment Date & Time:

Location of Service:

Wailea MODO MD VIP Urgent Care / Wellness Clinic located at 34 Wailea Gateway Place, Kihei, 96753

Other (enter below)

MOBILE DRIVE OUT FEES range $150-$250 depending on location and timing of the day. We are available 24/7 for testing.

Additional People Testing:

If having any trouble booking on-line please call or text 888-663-6631 (888) MODO-MD-1 for assistance.