Patient Information

• Ethnicity*
  • Hispanic or Latino
  • Non-Hispanic or Non-Latino
  • Unknown
• Race*
  • White
  • Black or African American
  • Asian
  • Native Hawaiian or Other Pacific Islander
  • American Indian or Alaskan Native
  • Other
• Pregnancy Status*
  • Pregnant
  • Not Pregnant
  • Unknown
  • Not Applicable
• Hosp. Status
  • Inpatient
  • Outpatient
  • Emergency Dept.
  • Unknown
• ICU
  • Yes
  • No
  • Unknown
• History of recent international travel?*
  • Yes
  • No
  • Unknown

Primary Care Provider

If applicable please fill out the fields below; If not applicable please indicate "N/A" in the Physician Name Field.

Submitting Facility / Laboratory Information

Specimen Information

Test Performed

We accept HSA/FSA cards. Itemized bill provided for insurance reimbursement. If Pay Pal is not your preferred method of payment, please proceed with the "Pay with Debit or Credit Card" option. For any additional insurance, payment or scheduling questions, please feel free to call our Rapid Test Specialist at (201) 425-1583 for an immediate response.

If testing for travel purposes, please consult with your airlines regarding requirements.