Laboratory Rapid Tests

Laboratory Rapid Tests

This form is to be filled out by those requesting to receive one of the Rapid tests outlined below. You will be contacted with results by the method you request.
Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Date
Gender

FemaleMale
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

My Products

Streptococcus (Strep)Time to results: 10 minutes

$25.00

COVID & Flu Antigen ComboTime to results: 20 minutes

$30.00

Enter coupon

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

I am or above named minor is...*

Under 3 years of age3 years of age or older
For children under the age of 3 years, if the streptococcus test results as positive we are unable to prescribe treatment. We encourage you to bring your results to your pediatrician, but cannot guarantee that they will be willing to prescribe treatment based off of a test they did not perform themselves.
I am or above named minor is...*

PregnantNot pregnant
For pregnant women, if the streptococcus test results as positive we are unable to prescribe treatment. We encourage you to bring your results to your obstetrician, but cannot guarantee that they will be willing to prescribe treatment based off of a test they did not perform themselves.
I am or above named minor is...*

ImmunocompromisedNot immunocompromised
Symptoms include... (check all that apply)*

Sudden onset of sore throatFever over 100.4HeadacheNausea/vomiting/abdominal painCough
The following test will be performed:*

Streptococcus (Strep)
The following test will be performed:*

Influenza (Flu)
The following test will be performed:*

COVID Antigen
The following test will be performed:*

COVID/Flu Antigen
How would you like your results delivered? (check all that apply)*

Phone callEmailI'll wait for a paper copy
Consent for person receiving testing:*

I understand that, as with any medical test, there is the potential for false positive or negative test results to occur. I understand if I have any unusual symptoms after testing, it is my responsibility to seek medical attention. I, the undersigned, have been informed about the test purpose, procedure, benefits, and risks. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask questions at any time. I voluntarily agree to be tested for the above chosen test(s).
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