Register now to get your test kit

Step 1 of 5

Patient Information
First Name*
Last Name*
Email*
Phone*
If ordering a test for a minor: Please make sure the minor’s information is provided in the registration process, not your own.

Insurance Information
Do you have insurance?*
- Yes
- No
Date of Birth*
This information is needed for your test result PDF.
Gender*
This information is needed for your test result PDF.
Parent First Name
Parent Last Name
Reason for testing*
Insurance Company*
Subscriber / Member ID*
Group Number
Are you the primary insurance member?*
- Yes
- No
Hidden
Insurance Card (Front)
Accepted file types: jpg, gif, png, Max. file size: 200 MB.
Hidden
Insurance Card (Back)
Accepted file types: jpg, gif, png, Max. file size: 200 MB.
Consent*
I understand that by submitting this order with my associated health insurance information, I consent to information about my testing and results being shared with the health insurer or government agency paying for my testing for purposes of payment, treatment, and/or healthcare operations, and as otherwise described in Fast Lab's HIPAA & Privacy Policy.
Terms of Use and Privacy Policy*
I have read and accept Fast Lab Tech’s Terms of Use and Privacy Policy*