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Please let us know the following to help prioritize your test -

Current Symptoms:
















Current Medical History:










Additional Questions:



Copy of Photo ID and Insurance Card: (Optional)
Taking a photo of your state-issued ID and insurance card (front and back) will save time at check-in.


License / ID Card

Insurance Front

Insurance Back

Acknowledgement and Authorization to Test:


I additionally provide consent for testing and reporting of results by electronic and telephonic means, including as a parent or legal guardian to minors that I may have registered.