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Sunday

December 05, 2021

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Step 1

Step 1

Personal Details

Registering Location

Are you doing registration at ?

Set Password
  •   Your password must contain at least one lower letter.
  •   Your password must contain at least one uppercase letter.
  •   Your password must contain at least one Number (0-9).
  •   Your password must contain at least one Special Character.
  •   Space is not allowed.
  •   Your password must be between 6 and 30 characters.
  •   Passwords do not match.
Patient Ethnicity
I consider myself: *
Patient Race
Which of the following racial designations best describes you (select one or more): *
Do You Have Insurance?
If you Don't have Insurance, Fill this CARES ACT Consent Form

Step 3 Title

Insurance / Payment Details

Do you have insurance? *
How will you be paying? *

Step 4 Title

Health

I have following condition(s): *
I have a condition that weakens my immune system or makes it harder to fight infections: *
I am taking one of these medications: *
I am or may be pregnant
I regularly use tobacco or nicotine products (e.g. cigarettes, e-cigarettes, vapes, hookah, etc.)
Have you possibly been exposed to the Coronavirus in the past 2 weeks? *
Yes, I have been in close proximity (within 6 ft.) to someone who has been diagnosed with or presumed to have COVID-19. *
Yes, I have been in close proximity (within 6 ft.) to someone who is sick but has not been diagnosed with COVID-19. *
Yes, I live, work or have visited a place where COVID-19 is widespread. *

Step 5 Title

Symptoms

Have you had any of the following symptoms since December 2019: *
Are you currently experiencing any of these symptoms? *
How did you hear about us?

Step 6 Title

Select Test Type
(FREE) - PCR Saliva/Rapid Antigen Test
PCR Saliva
Nasopharyngeal Swab
Antibody
Antigen
PCR Saliva/Nasopharyngeal Swab