Patient Pre-Registration

Register

Demographics

***Please ensure that the patient name and date of birth are identical to the information appearing on the patient's government issued ID***

Patient Last Name *

Patient First Name *

Middle Initial

Patient Date of Birth *

Patient Street Address *

Patient Address Line 2

Patient City *

Patient State / Province *

Patient Zip Code *

Patient Email Address *

Patient Mobile Number *

Sex *

Race *

Ethnicity *

Specimen Information

Test

Payment Method

How will payment be made? *

Primary Insurance

Insurance Provider *

Member ID *

Group Number (Optional)

Medical Insurance Card - FRONT *

Please take a photo of the front of your insurance card and upload.

Medical Insurance Card - BACK *

Please take a photo of the back of your insurance card and upload.

Patient Signature (Parent/Guardian signature for patients under 18)

Pay For Your Order

Cardholder Name*

Cardholder Email Address (to receive receipt) *

Card Information*

Billing Summary

Patient:

Test/Item	Price

Total Price:

Disclaimer

ProPhase COVID Test

* By checking this box, you agree to the disclaimer

*By clicking submit the patient gives authorization for test results and associated protected health information (PHI) to be sent via digital delivery methods including SMS text and email.