B2B Antigen Patient Intake | Fast Lab

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At home Covid Test

B2B Antigen Patient Intake

Step 1 of 5

20%

Patient Information
First Name*
Middle Initial
Last Name*
Email*
Phone*

Address
Home 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.

Reason for testing*
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
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
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