Patient Information
First Name*
Middle Initial
Last Name*
Email*
Phone*
If ordering a test for a minor: You must register with a separate email address for the minor or use the minor’s demographic information. Please make sure the minor’s insurance information is provided in the registration process, not your own.

Address
Home Address*
Apartment, Suite, Office
City*
State*
Zip*
has kit
I already have a kit
same address
Use home address as shipping address.
Shipping Address*
Apartment, Suite, Office
City*
State*
Zip*
Passport Information (for Travel)
using for travel
Are you using this for travel? (Check if yes)
Passport Number

Not all countries require a passport number but providing this will make it easier for you when boarding your flight.
Outgoing Shipping*
For faster delivery, please upgrade your outgoing shipping
Returns Shipping*
For faster returns, please upgrade your returns shipping
Date of Birth*
This information is needed for your test result PDF.
Gender*
This information is needed for your test result PDF.
Parent or guardian
(if below 18 years of age)
First Name
Last Name

Insurance Information
Do you have insurance?*
- Yes
- No
Reason for testing*
Subscriber / Member ID*
Insurance Company*
Insurance Company*
Group Number
Are you the primary insurance member?*
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.
Hidden
Driver's License or ID Card (Front)
Accepted file types: jpg, gif, png, Max. file size: 200 MB.
Hidden
Driver's License or ID Card (Back)
Accepted file types: jpg, gif, png, Max. file size: 200 MB.
Hidden
same insurance address
Use home address as insurance provider address.
Hidden
Insurance Provider Address (if applicable)*
Hidden
Apartment, Suite, Office
Hidden
City*
Hidden
State*
Hidden
Zip*
Hidden
Phone*
Race & Ethnicity*
(Check all that apply)
- American Indian or Alaska Native
- Native Hawaiian or other Pacific Islander
- Asian
- White
- Black or African American
- Hispanic or Latino
- Two or more races
- Other Race
- Prefer not to answer
Consent*
I understand that by submitting this COVID-19 Test request 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.
Please Note: All tests must be returned within the 15 days from the date of the receipt in order to avoid being directly billed.
Terms of Use and Privacy Policy*
I have read and accept Fast Lab Tech’s Terms of Use and Privacy Policy*

Review Order
Please review your information below and ensure all information is correct before placing your order.

Important: The person named below must be the person who is taking the test
{all_fields:nohidden}

Outgoing Shipping
For faster delivery, please upgrade your outgoing shipping
Returns Shipping
For faster returns, please upgrade your returns shipping
Total
$0.00
Payment
Card Details
Cardholder Name
same billing address
Use home address as billing address.
Hidden
Billing Address
Billing Address*
Apartment, Suite, Office
City*
State*
Zip*

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Step 1 of 5

Patient Information

Address

Passport Information (for Travel)

Parent or guardian

Insurance Information

Review Order

Billing Address