Patient Information
existing
I'm an existing patient
Email*
First Name*
Last Name*
Patients
We found multiple patients with this email. Please select the patient for the order.
If ordering a test for a minor: Please make sure the minor’s information is provided in the registration process, not your own.

Do you have insurance?*
- Yes
- No
Reason for testing*
Date of Birth*
Gender*
Phone*
Race*
Ethnicity*
Parent First Name
Parent Last Name
What type of insurance do you have*
- Medicare
- Medicaid
- Private
- Other
Insurance Company*
Subscriber / Member ID*
Insurance Company*
Group Number (Optional)
Are you the primary insurance member?*
- Yes
- No
Insurance Card - Front (Optional)
Accepted file types: jpg, gif, png, Max. file size: 200 MB.
Insurance Card - Back (Optional)
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 HIPAA & Privacy Policy*
Acknowledgement*
By writing my name below, I acknowledge that the insurance details I have provided are correct and I can be billed the full amount for the test kit if my insurance details are found to be invalid.
Name*

Fill in the form to place your order

Patient Information