Covid Test Registration for Travel

Agree to Terms & Conditions
By continuing, you agree:
- 1) You are 18 years old or older or 2) the parent or legal guardian of a minor patient 3 years old or older or 3) the legal guardian of the patient.
- You're not experiencing severe symptoms such as severe shortness of breath, continuous pain or pressure in the chest, or persistent fever greater than 102ºF. If you're experiencing severe symptoms, please seek medical attention immediately.
- You acknowledge that your or the minor patient’s information will be used as described in the Notice of Privacy Practices. Your personal health information may be made available electronically to other healthcare providers who have a treatment relationship with you or to your health plan for operations and care coordination as permitted by Federal and state laws.
- You agree to receive email communications that contain information about your or the minor patient’s eligibility for COVID-19 testing and COVID-19 testing appointments or results.
By selecting "I agree" below, you also have read and accepted our Terms of Use

Contact Info
Personal Email Address*

Confirmation Email
Contact Mobile Phone*
The phone number fields do not match!
By providing your mobile number, you consent to receive automated calls and/or text messages about this and follow-up visits, and to receive notification of test results when they are available.

Note: We may call you prior to your visit to confirm your personal details and eligibility. Results for a minor are only delivered by SMS or phone call to a parent or legal guardian.
Work Email Address (If Available)
Work Phone (If Available)

Patient Info

Fill the information as shown on your Passport
First Name*
Include Middle Name if any
Last Name*
Include second Last Name if any
Address

Street Address

Apartment, Suite or Room Number

CityState

Zip CodeCountry
Birthday*

MonthDayYear
Gender*

MaleFemale
Sex
Race*
Ethnicity*
Legal Representative First Name*
Legal Representative Last Name*

Passport Number*
Country*
Upload a Picture of your Passport*

Cancelof
Signature*

Clear
Bill to

Bill AccountMedicaidBill PatientMedicareInsurance
Date of Completion

MonthDayYear
Days
Age
Time

Hour Minutes
Diagnosis
Should be Empty: