Patient Pre-Registration

Register

Demographics

***Please ensure that the patient name and date of birth are identical to the information appearing on the patient's government issued ID***

Patient Last Name

Patient First Name

Middle Initial

Patient Date of Birth

Patient Street Address

Patient Address Line 2

Patient City

Patient State / Province

Patient Zip Code

Patient Email Address

Patient Mobile Number

Sex

Race

Ethnicity

Please upload an image of your id or enter your drivers license number.

Id Card (Parent/Guardian ID for patients under 18) Please take a photo of your id card and upload.

Drivers license number

Specimen Information

Test

Specimen ID

Specimen Source

Collection Date and Time

Payment Method

How will payment be made?

Patient Signature (Parent/Guardian signature for patients under 18)

Payment is requested for this order

Disclaimer:

I agree to the terms of service

You are paying for the COVID test. You will be charged USD $0

Enter your credit card information

*By clicking submit the patient gives authorization for test results and associated protected health information (PHI) to be sent via digital delivery methods including SMS text and email.