9647 Hillcroft St.                                                           
Houston, Texas
77096
 
Phone: (713) 242-8653
Email: info@rapiddxlabs.com

Patient Registration

Details must match your Government ID or Passport

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

Billing Information

Medicare -- Medical (Part B) Coverage *
Private Insurance Coverage *

Credit Card NOT REQUIRED if providing insurance card or VALID US ID if you select UNINSURED
Visa
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?
First COVID Test *
Are you employed in Healthcare? *
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.) *
 YesNo
Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)
Cough
Shortness of breath or difficulty breathing
New loss of taste or smell
Chills
Head or muscle aches
Nausea, diarrhea, vomiting
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? *
In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? *
Hospitalized in the last 14 days? *
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)? *
Pregnant? *
Traveled in the last 14 days? *

Completion

I hereby certify that the responses provided are true and accurate to the best of my knowledge. *
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