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 *

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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Visa

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.) *
 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
First COVID Test *
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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