subject_line
Patient Registration
Details must match your Government ID or Passport
First Name
*
Middle Name
*
Last Name
*
Sex
*
Female
Male
Identification Card
*
Provider Account
*
Curbside-100
200
-300
400
500
600
700
800
900
1000
Race
*
African American
Asian
Caucasian
Hispanic
Native American
Other
Ethnicity?
*
Hispanic / Latino
Non Hispanic/ Latino
Phone Number
*
Email Address
Provide only an ACTIVE email address, to recieve your results.
Date of Birth
*
Street Address
*
Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Billing Information
Medicare -- Medical (Part B) Coverage
*
YES
NO, I do not have Medicare -- Medical (Part B) Coverage
Private Insurance Coverage
*
Insured
Uninsured
Cash Pay
Insurance Card
Name on Card
By signing this document, I accept financial responsibility and am aware of the testing fees. I understand I am responsible for submitting my own insurance claim. As a Medicare patient, I am also aware that I am responsible for payment to Rapid DX LLC. If Medicare denies payment.
*
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Credit Card Type
Visa
MasterCard
American Express
Discover
Credit Card Number
Expiration Date (mm/yy)
Patient COVID-19 Screening Questionnaire
Representations
Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.)
*
Yes
No
Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)
Yes
No
Cough
Yes
No
Shortness of breath or difficulty breathing
Yes
No
New loss of taste or smell
Yes
No
Chills
Yes
No
Head or muscle aches
Yes
No
Nausea, diarrhea, vomiting
Yes
No
First COVID Test
*
Yes
No
In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?
*
Yes
No
In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?
*
Yes
No
Hospitalized in the last 14 days?
*
Yes
No
If Yes, Why?
Resident in a congregate care setting (including nursing homes, residential care for intellectual and developmental disabilities, psychiatric treatment facilities, group homes, board and care homes, homeless shelter, foster care or other setting)?
*
Yes
No
Pregnant?
*
Yes
No
Traveled in the last 14 days?
*
Yes
No
Completion
I hereby certify that the responses provided are true and accurate to the best of my knowledge.
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Date
*