Patient Information
First Name*
Middle Initial
Last Name*
Email*
Date of Birth*
Parent/Guardian First Name
Parent/Guardian Last Name
Address Information
Home address*
Apartment, Suite, Office
City*
State*
Zip*
Insurance Information
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.
Consent*
The information provided here is accurate and correct, and that Fast Lab will be using my insurance information to pay for my COVID test.
Terms of Use and Privacy Policy*
I have read and accept Fast Lab Tech’s Terms of Use and Privacy Policy*

Patient Information

Address Information