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)

Payment is required before placing this order

Disclaimer:

ProPhase COVID Test

I agree to the terms of service

You are paying for the COVID-19 Antigen test. You will be charged USD $0

Enter your credit card information

*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.