Patient Information
If ordering a test for a minor: Please make sure the minor’s information is provided in the registration process, not your own.
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*
On-site Location*

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.

Test Type*
Reason for testing*
Do you have insurance?*
- Yes
- No
Date of Birth*
Gender*
Parent First Name
Parent Last Name
Insurance Company*
Subscriber / Member ID*
Insurance Company*
Group Number
Are you the primary insurance member?*
- Yes
- No
You may upload your insurance card to speed up the verification process.
Insurance Card (Front)*
Accepted file types: jpeg, jpg, gif, png, heif, heic, Max. file size: 200 MB.
Insurance Card (Back)*
Accepted file types: jpeg, jpg, gif, png, heif, heic, Max. file size: 200 MB.
Driver's License or ID Card (Front)
Accepted file types: jpeg, jpg, gif, png, heif, heic, Max. file size: 200 MB.
Driver's License or ID Card (Back)
Accepted file types: jpeg, jpg, gif, png, heif, heic, Max. file size: 200 MB.
Hidden
Insurance Provider Address (if applicable)*
Hidden
Apartment, Suite, Office
Hidden
City*
Hidden
State*
Hidden
Zip*
Hidden
Phone*
How did you hear about us?*
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 paying for my testing for purposes of payment, treatment, and/or healthcare operations, and as otherwise described in Fast Lab’s HIPAA & Privacy Policy.
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}

Test Type*
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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Patient Information

Passport Information (for Travel)

Review Order

Billing Address