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Antigen Test Online Patient Registration
All the below fields are mandatory*
Antigen Test Lab Visit
Antigen Test Home Collection
Antigen Test Lab Visit
Bill Type (Please select one)
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Insured
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Client Bill
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*
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Medicaid
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First Name
*
Last name
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Email Address
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Telephone or FAX
*
Date of Birth
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SSN / Passport / Driver's License / State ID
Street Address
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Apartment, suite, etc
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ZIP / Postal Code
Race and Ethnicity
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Gender
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Policy ID Number
Group Number
Relartionship to Insured
*
Self
Spouse
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Other
First Name
Middle Initial (if different from patient)
Last Name
(if different from patient)
Date of Birth
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Do You Have A Flight
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Flight Date
Please select the date when you have your flight.
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Upload Picture
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Upload ID
Choose File
No file chosen
Delete uploaded file
Upload Insurance Card
Choose File
No file chosen
Delete uploaded file
Select Test
Rapid Flu A&B Test at $55
Request Quote
Please do not fill in this field.
Antigen Test 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
13
14
15
16
17
18
19
20
21
22
23
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
Rapid Flu A&B Test at $99
Request Quote
Please do not fill in this field.
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