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.

Reason for Testing (Choose multiple if applicable)*
- Exposed to Covid-19
- Fever or chills
- Cough
- Difficulty breathing
- Fatigue
- Muscle or body aches
- Headache
- Loss of taste/smell
- Sore throat
- Congestion or runny nose
- Nausea or vomiting
- Diarrhea
- Medical referral
- None of these
Do you have insurance?*
- Yes
- No
Sorry! we are currently only accepting patients that have insurance.
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*
Group Number (Optional)
Are you the primary insurance member?*
- Yes
- No
Hidden
Insurance Card - Front (Optional)
Accepted file types: jpg, gif, png, Max. file size: 200 MB.
Hidden
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 as described in Fast Lab's HIPAA & Privacy Policy.

I have read and accept Fast Lab Tech’s Terms of Use and HIPAA & Privacy Policy
Acknowledgement*
By checking this box 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.
No. of PCR Tests*
No. of Antigen Tests*

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Patient Information