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
Select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Patient Zip Code
Patient Email Address
Patient Mobile Number
Sex
Select...
Male
Female
Other
Unknown
Race
Select...
American Indian or Alaska Native
Asian
Black or African American
Multi-racial
Native Hawaiian or other Pacific Islander
White
Other
Unknown
Prefers not to share
Ethnicity
Select...
Hispanic or Spanish origin
Not Hispanic or Spanish origin
Prefers not to share
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
Parent/Guardian Minor Consent
Parent/Guardian Name
Relationship To Patient
Specimen Information
Test
Select test...
COVID
Rapid Antigen COVID
Specimen ID
Specimen Source
Select source...
Collection Date and Time
Payment Method
How will payment be made?
Select...
Client Bill
Patient Signature (Parent/Guardian signature for patients under 18)
Clear Patient Signature
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
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*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.
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