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

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
Note: Orders placed after 4PM EDT. will be shipped the next day.

Do you have insurance?*
- Yes
- No
Reason for testing*
How did you hear about us?*
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
Insurance Company*
Subscriber / Member ID*
Insurance Company*
Group Number (Optional)
Are you the primary insurance member?*
- Yes
- No
You may upload your insurance card to speed up the verification process.
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.
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*
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 PCR tests must be returned within 7 days from the date of the receipt in order to avoid being directly billed. COVID Test Kits cannot be returned unused. If you return your kit unused or discard your kit, you will be billed directly.
Terms of Use and Privacy Policy*
I have read and accept Fast Lab Tech’s Terms of Use and 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*

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
Notes:
- Orders placed after 4PM EDT. will be shipped the next day.
- The 2-Day and Overnight shipping does not include weekends and holidays.
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

Passport Information (for Travel)

Review Order

Billing Address