Advanced Testing Services

1
Patient Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Gender* This field is required.
Female
Male
4
Mobile Phone* This field is required.You will receive your results by text message
(###) ###-####
5
Home Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Race* This field is required.
American Indian / Alaskan Native
Black / African American
White / Caucasian (Non-Hispanic)
Hispanic / Latino
Other
Decline to Self-identify
7
Email
example@example.com
8
Do you have any of the following symptoms?* This field is required.
Cough
Fever
Shortness of Breath
Fatigue
Runny Nose
Sore Throat
Loss of Taste or Smell
No Symptoms
9
Appointment
10
Do you have health insurance?* This field is required.
YESNO
11
Social Security Number* This field is required.##-##-####
12
Insurance Coverage:* This field is required.Is this insurance your own or through a spouse/other? Select one of the following
Self
Spouse
Other
13
Name of Primary Policy Holder* This field is required.
First Name
Last Name
14
Primary Policy Holder's Date of Birth* This field is required.
Date
Year
Month
Day
15
Select Your Health Plan or Insurance Company* This field is required.
Blue Cross Blue Shield
Aetna
Cigna
United Healthcare
Humana
Medicare
Medicaid
Other
16
Name of Your Health Plan* This field is required.
17
Upload a Picture of the Front of Your Insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
18
Upload a Picture of the Back of Your Insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
19
Insurance ID Number* This field is required.
20
Insurance Group number. * This field is required.
21
Upload a Picture of the Front of Your Driver's License.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
22
Upload a Picture of the Back of Your Driver's License.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
23
Patient Consent and Authorization* This field is required.I hereby authorize Flow Health, its subsidiary, and affiliated receiving and/or performing laboratories (collectively herein, "Laboratory") and/or its authorized agents, to run the specified tests on my blood and other specimens/samples and agree to the terms and conditions https://flowhealth.com/notice-of-privacy-practices and https://flowhealth.com/patient-terms. I understand that as a courtesy, Laboratory and/or its authorized agents will make every reasonable effort to obtain insurance reimbursement for ordered tests. I understand that I am making an assignment of my insurance plan benefits to Laboratory and/or its authorized agents. I also authorize the release of any information contained in my records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with the same. I understand that if my insurance company pays me directly for services rendered by Laboratory, I am responsible for forwarding such payment to Laboratory.
Clear
Should be Empty: