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***

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* Please take a photo of your id card and upload.
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Specimen Information
Payment Method
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Primary Insurance
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Please take a photo of the front of your insurance card and upload.
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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

*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.