9647 Hillcroft St.

Houston, Texas

77096

Phone: (713) 242-8653

Email: info@rapiddxlabs.com

Patient Registration

Details must match your Government ID or Passport

First Name *

Middle Name

Last Name *

Date of Birth in this format mm-dd-yyyy *

Gender *

Identification Card of the patient or of the patient's legal guardian *

Phone Number *

Email Address *

Provide only an ACTIVE email address, to recieve your results.

Ethnicity? *

Race *

Street Address *

Address Line 2

City *

State *

Zip Code *

If traveling out of country it may be beneficial to include your Passport Number. If you would like this included within your report please add it here:

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/ Credit Card

Insurance Card (Medicare/ Medicaid or private insurance)

Credit Card NOT REQUIRED if providing insurance card or VALID US ID if you select UNINSURED

Name on Card

Credit Card Number

Credit Card Type

Expiration Date (mm/yy)

CVC#

By signing this document, I attest that the above mentioned financial information is true and accurate to the best of my knowledge. Rapid Dx Labs may contact me should they experience issues with the indicated payment options or other concerns. *

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Patient COVID-19 Screening Questionnaire

Representations

Is this COVID Test needed for travel purposes?

Yes

No

If so, which country will you be travelling to?

First COVID Test *

Yes

No

Are you employed in Healthcare? *

Yes

No

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

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

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 (mm/dd/yyyy) *