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Patient Registration

We need to collect a few details before we can begin testing.

This information is collected to send results to you directly through our patient portal. Be sure to enter all information accurately to receive your results quickly.

This form is secure and HIPAA-compliant .

Patient In-Take Form

Personal Information:

First Name:

Last Name:

Email:

Sex:

Street Address:

City:

State

Zip Code:

Contact Number:

Date of Birth

Testing Program:

What School, Business or Event you are being tested for?

Are you an employee, staff, or member of the faculty?

Yes

No

Choose a test collection method:

Saliva Swab ( Limited quantity - priority availability to children under 9).

Nasal Swab.

Medical Information:

Are you experiencing any flu like symptoms?

Fever

Cough

Chills

Shortness of Breath

Sore Throat

Diarrhea

Fatigue

Headache

Congestion

Loss of taste or smell

Vomiting

Nausea

None

Are you experiencing any flu like symptoms?

Fever

Cough

Chills

Shortness of Breath

Sore Throat

Diarrhea

Fatigue

Headache

Congestion

Loss of taste or smell

Vomiting

Nausea

None

Do you have any medical conditions?

Weakened Immune System

Diabetes

Chronic Lung Disease

Chronic Liver Disease

Cardiovascular Disease

Kidney, Renal Disease

Cancer

Obesity

Pregnancy

Do you smoke or vape?

Are you a former smoker?

Did you receive a flu shot?

None

Do you take any medications?

No

Yes

COVID-19 Information:

Have you previously tested positive for COVID-19?

No

Yes

Do you suspect you've been exposed to COVID-19 directly or indirectly?

No

Yes

Insurance Information:

Do you have insurance?

No

Yes

Insurance Company:

Member ID or Policy number:

Group ID number:

Policy holder's full name:

Relationship to Policy:

Driver's License / Insurance Card:

Driver's License (Front):

Upload File

(Max 15MB)

Insurance Card (Front):

Upload File

(Max 15MB)

Insurance Card (Back):

Upload File

(Max 15MB)

Sign and Submit:

This information is accurate to the best of my knowledge.

Initials

Thanks for submitting!

HEALTHY PEOPLE. SAFE PLACES.

On-Site testing solutions and strategies.

Read our Terms and Conditions.

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