COVID-19 Test Registration

Fields marked with * are required.

First Name

Middle Name

Last Name

Date of Birth (MM-DD-YYYY, Enter just the numbers w/o the hyphens (dashes))

Gender

Email Address

Cell Phone No.

Other Phone No.

Street Address

City

State

ZipCode

Country

Your Race

Your Ethnicity

What tests are you requesting?
COVID-19 Serum IgM Testing
COVID-19 PCR Testing
COVID-19 Antigen Testing

Password to View Report(6 to 8 characters with alphabets & numbers and no special symbols. Link to view will be sent via email. Take a picture for future use.)

Note: Take pics from close to fill the screen. Allow time for camera to focus. Hold camera steady while clicking. Preview the image. Retake, if you can't read.

Photo ID(e.g. Passport picture page, driver's license, etc. Change your camera/photo settings to files of max file size of 6MB and image types of JPG, PNG, or PDF.)

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How do you want to pay? Insurance Credit Card on Site Cash on Site

Insurance Card Front (Change your camera/photo settings to files of max file size of 6MB and image types of JPG, PNG, or PDF.)

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Insurance Card Back (Change your camera/photo settings to files of max file size of 6MB and image types of JPG, PNG, or PDF.)

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Are you pregnant? No Yes

Is this your first COVID-19 test?
Yes No

Are you exhibiting COVID-19 symptoms?
Yes No

Start Date

Symptoms

Additional Information

Patient Privacy Notice and Acknowledgement

We are required by law to provide you this notice about how we plan to use and share your health information. Based on your request for testing, we plan to use and share your health information provided in compliance with the HIPAA guidelines. It is your right to have your personal health information to be used for purposes only for which it is intended and to be shared to fulfill your request accordingly. The Privacy Rule allows provider to use and disclose protected health information. Your permission (authorization) is necessary before your health records are shared for any other reason.

The law requires us to ask you to state in writing that you received the notice. But you are not required to sign. Signing does not mean that you have agreed to any special uses or disclosures (sharing) of your health records. Refusing to sign the acknowledgement does not prevent a provider or plan from using or disclosing health information as HIPAA permits but we must keep a record this fact.

You have your privacy rights, including the right to complain to Health and Human Services and to the organization if you believe your privacy rights have been violated. For details visit the HHS website. You may view this policy at our website, www.GoPathLabs.com any time.