PRODUCT

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Patient Information

Name

First Last

If ordering a test for a minor: Please make sure the minor’s information is provided in the registration process, not your own.

Home Address

Street Address Apartment, Suite, Office City State ZIP Code

address check

Use home address as shipping address.

Shipping Address

Street Address Apartment, Suite, Office City State ZIP Code

Do you have insurance?*

Yes

Reason for testing*

Date of Birth*

Gender

Phone

Race*

Ethnicity*

Insurance Company*

Subscriber / Member ID*

Consent

I understand that by submitting this order with my associated health insurance information, I consent to information about my testing and results being shared with the health insurer or government agency paying for my testing for purposes of payment, treatment, and/or healthcare operations, and as otherwise described in Fast Lab's HIPAA & Privacy Policy.

Consent

I have read and accept Fast Lab Tech’s Terms of Use and HIPAA & Privacy Policy*

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PRODUCT

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Patient Information

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