Language
English (US)
Spanish (Latin America)
Patient Details
COVID Testing
Patient Registration and Screening
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Sex
*
Please Select
Male
Female
N/A
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race (Check all that apply)
African American
White
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Unkown
Other
Ethnicity
Hispanic
Not Hispanic
Health Insurance Information
Insurance Name
*
from your insurance card
Identification Number
*
from your insurance card
Group Number
*
also from your insurance card
Insurance Card
Photo Upload
Drag and drop files here
Choose a file
Please submit a photo of your insurance card.
Cancel
of
The cost of providing COVID-19 testing at our facilities is fully covered by all insurance providers with no out of pocket cost to our patients. Participants must provide a copy of their medical insurance at the time of sample collection in order to receive a COVID-19 test.
Email
*
Phone Number
*
Please enter a valid phone number.
Back
Next
Health Screening
Are you experiencing any of the following symptoms?
*
None, Screening Only
Fever
Potential COVID-19 Exposure
Cough
Fatigue
Loss of Taste or Smell
Sore Throat
Shortness of Breath
Congestion
Runny Nose
Nausea
Vomiting
Headache
Other
Have you had contact with anyone who has COVID-19 or COVID-like symptoms within the past 14 days?
*
Yes
No
Back
Next
Consent for Testing
HIPPA Authorization Form
I, the undersigned, have read and agree to the terms and conditions associated with receiving PCR COVID-19 testing results and I am voluntarily supplying my sample for testing.
*
Submit
Should be Empty: