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rtPCR test results in 60 minutes at $175
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rtPCR Home Collection
Bill Type (Please select one)
*
Insured
Un-Insured
Client Bill
Commercial Insurance Policy
*
Medicare
Medicaid
Tricare
First Name
*
Last name
*
Email Address
*
Telephone or FAX
*
Date of Birth
*
SSN / Passport / Driver's License / State ID
Street Address
*
Apartment, suite, etc
City
*
State/Province
*
ZIP / Postal Code
Race and Ethnicity
American Indian or Alaska Native
Caucasian
Asian
Black or African American
Pacific Islander
Hispanic or Latino
Other
Gender
Male
Female
Policy ID Number
Group Number
Relartionship to Insured
*
Self
Spouse
Child
Other
First Name
Middle Initial (if different from patient)
Last Name
(if different from patient)
Date of Birth
Appointment date
Hours
Minutes
AM
PM
Do You Have A Flight
No
Yes
Flight Date
Please select the date when you have your flight.
Flight Time
Hours
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Minutes
00
01
02
03
04
05
06
07
08
09
10
11
12
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14
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18
19
20
21
22
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24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Upload Picture
Choose File
No file chosen
Delete uploaded file
Upload ID
Choose File
No file chosen
Delete uploaded file
Upload Insurance Card
Choose File
No file chosen
Delete uploaded file
Select Test
rtPCR test results in 60 minutes at $219
Request Quote
Please do not fill in this field.
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