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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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First Name
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Email Address
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Apartment, suite, etc
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ZIP / Postal Code
Race and Ethnicity
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Group Number
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*
Self
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First Name
Middle Initial (if different from patient)
Last Name
(if different from patient)
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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
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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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