Register For COVID-19 Testing

Unknown Organization Name: Register For COVID-19 Testing

If you already have an account with us, please login at the login page.

Demographic Information

First Name

Last Name

Telephone

Date of Birth

Gender

Race

Ethnicity

Passport No. (optional)

Guardian Contact Info

Required if the person being tested is a minor or has a legal guardian.

Guardian First Name

Guardian Last Name

Guardian Contact Phone

Guardian Contact Email

Address

I need to enter a non-US address

Street

Address Line 2

City

State

ZIP Code

Country Name

Subdivision (Province etc)

Your Address Within Your Country

Your ID within Your Country

Your Passport Number

Medical Insurance Info

Insurace information is required if you have medical insurance.

I claim that I do not have medical insurance. I will upload my ID card or enter my SSN.

I do not have medical insurance. I will pay out of pocket for Test.

Insurance Company Name

Your Insurance Subscriber ID

Insurance Group Number (if available)

Patient Relation to Subscriber

Subscriber Gender

Insurance Subscriber Date of Birth (mm-dd-yyyy)

Insurance subscriber info is different from the person under registration

Insurance Subscriber First Name

Insurance Subscriber Last Name

Insurance Subscriber Street

Insurance Subscriber City

Insurance Subscriber State

Insurance Subscriber ZIP Code

Insurance Subscriber Phone

Insurance or ID Card

Upload your insurance card or ID card (such as state drivers license card, state ID card), or enter your SSN or your state drivers license number or state ID number.

Insurance or ID Card Front

Insurance or ID Card Back

Goverment ID Number

Or Social Security Number 000-00-0000

I claim that I am NOT INSURED, and attest that I do NOT have, or do NOT wish to provide SSN or ID card information.

Your Password

Please choose a password for your account.

A good password is "complex", easy for you to remember but hard for others to guess.

Create Your Password

Confirm Password

You must agree to the Disclaimer and Consent form to register.

I have read and acknowledge the Disclaimer

I have read and acknowledge the Consent form