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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.

Do you have insurance?*
- Yes
- No
Reason for testing*
Sorry! we are currently only accepting patients that qualify for $0 tests and 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 paying for my testing for purposes of payment, treatment, and/or healthcare operations, and as otherwise 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.
Orders placed after 4PM EST. will be shipped the next business day.
No. of PCR Tests*
No. of Antigen Tests*

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Patient Information