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
- Chills
- Cough
- Difficulty breathing
- Fatigue
- Muscle or body aches
- Headache
- Loss of taste/smell
- Sore throat
- Congestion or runny nose
- Nausea
- Vomiting
- Diarrhea
- Medical referral
- Other
Other Symptoms*
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*
Please enter your Insurance Company*
Subscriber / Member ID*
Group Number (Optional)
Are you the primary insurance member?*
- Yes
- No
You may upload your insurance card to speed up the verification process. There may be a 2 to 3 day delay in verifying your insurance if you don't upload your ID.
Insurance Card - Front (Optional)
Accepted file types: jpg, gif, png, Max. file size: 200 MB.
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
Assignment of Benefits*
I hereby authorize my Insurance Company to pay by check made payable and mailed directly to: FAST LAB TECHNOLOGIES, LLC for the medical and surgical benefits allowable, and otherwise payable to me under my current insurance policy, as payment toward the total charges for the services rendered. I understand that as a courtesy to me, Fast Lab Technologies, LLC will file a claim with my insurance company on my behalf. However, I am financially responsible for, and hereby do agree to pay, in a current manner, any charges not covered by the insurance payment. If it is necessary to file a formal collection action, I agree to pay all costs, including reasonable attorney’s fees incurred by Fast Lab Technologies, LLC in the collection of the outstanding fees. Actual Plan Benefits cannot be determined until the claim is received by your insurance company and is based upon their determination of medical necessity. The information received from the above stated is not a guarantee of payment.
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