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April 23, 2024
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Step 1 Title
Step 1
Personal Details
First Name
*
Middle Name
Last Name
*
2nd Last Name
Phone Number
*
Gender
*
Select Gender
Male
Female
Prefer not to disclose
D.O.B.
*
Email Address
*
Confirm Email Address
*
Altername Email Address (Optional)
Student/Faculty ID
Kit ID
Registration for Individual or Family
Individual
Family
Family Details
Enter Second Member Details
Name
Phone
Email
Gender
Male
Female
Relation
Father
Mother
Husband
Wife
Brother
Sister
Son
Daughter
Other
Kit ID
Enter Third Member Details
Name
Phone
Email
Gender
Male
Female
Relation
Father
Mother
Husband
Wife
Brother
Sister
Son
Daughter
Other
Kit ID
Enter Fourth Member Details
Name
Phone
Email
Gender
Male
Female
Relation
Father
Mother
Husband
Wife
Brother
Sister
Son
Daughter
Other
Kit ID
Enter Fifth Member Details
Name
Phone
Email
Gender
Gender
Male
Female
Relation
Father
Mother
Husband
Wife
Brother
Sister
Son
Daughter
Other
Kit ID
Add Third Member
Add Fourth member
Add Fifth Member
Street Address
*
Suite/Apt#
Additional Address
Additional Address,
Zip Code
*
City
*
State
*
Country
*
Passport Number
(Travel Purposes Only)
Set Password
Password
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Your password must contain at least one uppercase letter.
Your password must contain at least one Number (0-9).
Your password must contain at least one Special Character.
Space is not allowed.
Your password must be between 6 and 30 characters.
Confirm Password
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Patient Ethnicity
I consider myself: *
Not Hispanic or Latino
Hispanic or Latino
Rather not specify
Patient Race
Which of the following racial designations best describes you (select one or more): *
American Indian or Alaska Native
Asian
Black or African American
Native hawaiian or Other Pacific Islander
White
Rather not specify
How did you hear about us?
Google
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Word of Mouth
News
Other
Please Share the Source
In addition to E-Mail, I want to receive my Patient QR-Code through this notification type:
Text/SMS:
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Step 2 Title
Health Insurance Details
Do You Have Insurance?
Yes
No
Health Insurance Details
Insurance
Insured Is
Patient
Parent
Guardian
Spouse
Other
If Insured is
NOT PATIENT
include following
First Name
*
Middle
Last
*
D.O.B
*
Street Address
*
Suite/Apt#
Address 3
Additional Address
Zip Code
*
City
*
State
*
Country
*
Member ID #
*
Group ID #
Out of Network Coverage?
Yes
No
Medicare
PPO
POS/EPO
HMO
Medicaid
Tricare/Military
Active Now?
Yes
No
Insurance Start Date
Deductibles Met?
Yes
No
Co-Insurance (Supplemental Plan B, or Other)?
Yes
No
If yes, Insurance
Insurance Name
Please upload images in jpg and png format only and upto 2 MB size.
Upload Government Issued ID
Upload
Upload Insurance Front Side
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Upload Driving License Back Side
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If you Don't have Insurance, Fill this
REQUISITION Form
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Upload Insurance Back Side
Upload
Step 3 Title
Insurance / Payment Details
Do you have insurance? *
Yes
No
How will you be paying? *
Cash
Credit Card
Insurance
Step 4 Title
PRE-EXISTING CONDITIONS
Do You Have Any Pre-Existing Conditions?
Yes
No
I have following condition(s): *
High Blood Pressure
Heart disease (e.g. previous heart attacks, heart failure, etc.)
Diabetes
Over weight or obesity
Kidney disease or other neurological condition affecting my ability to cough
Liver disease
Lung disease
Does not apply
If Other, Specify
I have a condition that weakens my immune system or makes it harder to fight infections: *
HIV
Cancer
Lupus
Rheumatoid Arthritis
Solid organ or bone marrow transplant
Does not apply
If Other, Specify
I am taking one of these medications: *
Steroids
Chemotherapy
Immunosuppressants
None of the Above
I am or may be pregnant
Yes
No
Yes, I live, work or have visited a place where COVID-19 is widespread. *
Yes
No
Have you possibly been exposed to the Coronavirus in the past 2 weeks? *
Yes
No
Yes, I have been in close proximity (within 6 ft.) to someone who has been diagnosed with or presumed to have COVID-19. *
Yes
No
Yes, I have been in close proximity (within 6 ft.) to someone who is sick but has not been diagnosed with COVID-19. *
Yes
No
Do you have Diabetes Mellitus?
Yes
No
Are you suffering from Cardiovascular disease?
Yes
No
Are you suffering from Chronic Renal disease?
Yes
No
Are you suffering from Chronic Liver disease?
Yes
No
If female,are you currently pregnant?
Yes
No
Do have Immuno disorder?
Yes
No
Are you suffering from Neurological disability?
Yes
No
Are you suffering from Intellectual disability?
Yes
>
No
Do you have Other chronic diseases?
Yes
No
Do you have any Chronic Lung disease(asthma/emphysema/COPD)?
Yes
No
Other,specify
EXPOSURE
Travel to a non-US country with a lab-confirmed SARS-CoV-2 (COVID-19) patient?
Yes
No
In the last 14 days, have you come into contact with a person(s) known to be infected with COVID-19? *
Yes
No
If yes, was this person a U.S. case?
Yes
No
Step 6 Title
Have you had any of the following symptoms since December 2019: *
Fever, at least 100.3 F, or feeling feverish, or feel warm to the touch
Dry cough, new or worsening
Sinusitis or sinus pain
Loss of smell or taste
Runny nose or stuffy nose
Chills
Feeling tired, fatigue
Headache
Sore throat, new or worsening
Shortness of breath, particularly with simple activities
Muscle pain/aches or joint pain
Diarrhea
Vomiting
Red/purple bumps on hands or toes/feet, painful or sore to touch
Pink eye
Expectoration (ex phlegm or mucous)
None of the above
Are you currently experiencing any of these symptoms? *
Yes
No
ABSENT (No symptoms) - 0
Mild (Present, but minimal) - 1
MODERATE(tolerable) - 2
Severe - 3
Symptoms
Nasal discharge(runny nose)
0
1
2
3
Nasal obstruction (stuffy nose)
Nasal itching
Itchy ears
Itchy eyes
Itchy throat
Watery eyes
Gritty feeling(eyes)
Sensitivity to pet hair
Hives
Eczema
Sneezing
Sinus pressure
Sinus_pain
Sinus or ear infections
Wheezing
Difficulty breathing
Shortness of breath(Dyspnea)
Frequent colds or sore throat
Cough
Headache
Fever/Chills
Muscle aches(myalgia)
Diarrhea
Abdominal pain
Nausea or vomiting
Loss of smell or taste
Feeling tired,fatigue
Red/Purple bumps on hands or toes/feet
Pinkish Eyes
Expectoration (Phalegm or Mucous)
Step 7 Title
ASTHMA/ALLERGY HISTORY
Do You Have Allergies?
Yes
No
Which seasons do you experience severe allergies? (Check all that apply)
SPRING
SUMMER
FALL
WINTER
How many months during the year do you experience allergies?
How many years have you suffered from allergies?
Who else in your family has allergies?
Have you ever had an allergy test before?
Yes
No
If yes, which type?
FINGER STICK
BLOOD DRAW
SKIN
PATCH
Have you ever had a reaction to a stinging insect?
Yes
No
If yes, which type of reaction?
HIVES(Urticaria)
SHORTNESS OF BREATH(Dyspnea)
LIGHTHEADED, BLACKOUT (Pre-syncope/Syncope)
VOMITING/DIARRHEA
Have you ever received allergy shots?
Yes
No
Allergy drops?
Yes
No
If yes, approximate year
Do you smoke or use tobacco products?
Yes
No
I regularly use tobacco or nicotine products (e.g. cigarettes, e-cigarettes, vapes, hookah, etc.)
Yes
No
List any animals you are around on a regular basis.
Did the patient have another diagnosis/etiology for their illness?
Yes
No
If yes, what diagnosis?
Does the patient have an abnormal chest X-ray?
Yes
No
Does the patient have acute respiratory distress syndrome?
Yes
No
ASTHMA/ALLERGY MEDICATIONS
Antihistamines
0
1
2
3
Eye drops
Ointments
Nasal steroids(Flonase, Nasacort)
Oral steroids
Asthma medication(Inhaler, Singulair, Advair)
Other allergy medications?
If yes:
Patient
Visitor
Health Care Worker
Animal
Contact with another lab-confirmed SARS-CoV-2 (COVID-19) case-patient?
Yes
No
If yes, U.S. case, then source:
Patient
Visitor
Health Care Worker
Animal
Unknown
Other
Is the patient a health care worker in the United States?
Yes
No
If yes, specify location:
Other specify
Symptomatic
Asymptomatic
Unknown
If symptomatic, approximate onset date (MM/DD/YYYY):
Step 6 Title
Test Type
Select Test Type
Rapid Antigen Test (Boson)
Toxicology
RT-PCR Multiplex (COVID-19, FLU A/B, RSV)
Paired (Multiplex Covid-19, FluA/B, RSV/Rapid Anti
Select the Type of Test to be Conducted
Consent Form
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I hereby,
Agree and consent to the
PRIVACY POLICY,
TERMS OF SERVICE
, and the
Consent Form:
Policy
I am signing as *
The Patient
The Patient's Legally Authorized Representative
Representative Full Name
Witness Full Name
REQUISITION Form
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PATIENT INFORMATION
First Name
Middle Name
Last Name
Date of Birth
Age
Sex
Street
City
State
Zip Code
Phone
SSN
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State Identification / Driver's License
Agreement / Signature
Patient Certification: By signing this form, the medical professional acknowledges that the individual/family member authorized to make decisions for the individual (collectively, the “Patient") has been supplied information regarding and consented to undergo selected testing. No test other than the specific test ordered shall be performed on the biological sample.
Yes
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