First Name*

Last Name*

Date of Birth*

Gender*

Male

Female

Race*

Ethnicity*

Address*

City*

State*

Zip Code*

Mobile Phone* Format: 5553334444

Email*

Photo of ID

SSN

Passport Number

Photo of prescription

I don't have insurance (If you HAVE insurance and don't provide it, you will be BILLED!)

Primary Insurance*

Insurance ID#*

Group # (Optional)

Picture of Insurance Card (front)

Picture of Insurance Card (back)

Primary Physician Name (Optional)

Physician Phone (Optional) Format: 5553334444

Experiencing signs/symptoms associated with COVID-19

Cough

Shortness of breath

Fever, unspecified

Suspected exposure to COVID-19

Previously had COVID-19

Exposure

Travel

Surgery

You must acknowledge and authorize in order to submit this form.

I understand that this specimen must be shipped the same day it is collected, otherwise, the lab is not permitted by the FDA to process this test.
You must acknowledge that the sample was collected same day as sent to lab.

Collection Date*

Time of collection*