Patient Pre-Registration

Register

Demographics

***Please ensure that the patient name and date of birth are identical to the information appearing on the patient's government issued ID***

Patient Last Name *

Patient First Name *

Middle Initial

Patient Date of Birth *

Patient Street Address *

Patient Address Line 2

Patient City *

Patient State / Province *

Patient Zip Code *

Patient Email Address *

Patient Mobile Number *

Sex *

Race *

Ethnicity *

Please upload an image of your id or enter your drivers license number.

Id Card (Parent/Guardian ID for patients under 18) * Please take a photo of your id card and upload.

Drivers license number *

Specimen Information

Test

Specimen ID

Specimen Source

Collection Date and Time

Payment Method

How will payment be made? *

Primary Insurance

Insurance Provider *

Member ID *

Group Number (Optional)

Medical Insurance Card - FRONT *

Please take a photo of the front of your insurance card and upload.

Medical Insurance Card - BACK *

Please take a photo of the back of your insurance card and upload.

Secondary Insurance

Insurance Provider *

Member ID *

Group Number (Optional)

Medical Insurance Card - FRONT *

Please take a photo of the front of your insurance card and upload.

Medical Insurance Card - BACK *

Please take a photo of the back of your insurance card and upload.

Tertiary Insurance

Insurance Provider *

Member ID *

Group Number (Optional)

Medical Insurance Card - FRONT *

Please take a photo of the front of your insurance card and upload.

Medical Insurance Card - BACK *

Please take a photo of the back of your insurance card and upload.

Patient Signature (Parent/Guardian signature for patients under 18)

I understand that the above referenced test is patient-initiated, which Incyte Diagnostics can perform without a physician’s order. I further understand that Incyte Diagnostics will perform the testing and provide me with my results, but that Incyte Diagnostics cannot interpret or treat me for any medical condition(s) found as a result of this test(s). I authorize Incyte Diagnostics to report my test results securely through the LabSender portal. I authorize Incyte Diagnostics to collect my nasal swab specimens for analysis. I understand that my test results will be communicated exclusively to me and will not be sent to any physician or healthcare provider or released to another party without my consent, unless required by law. By voluntarily participating in this testing, I recognize and accept all risks associated with the Direct to Consumer program. I understand the results of the test do not constitute a complete medical examination or diagnosis. For diagnosis of a medical problem, I must see a provider for a complete medical examination. I understand that a physician’s order is not required for this testing today. I understand that the tests I am electing to have performed will not be billed to my insurance and that payment for this test is due at the time of service. No specimen will be processed until payment is made in full. Acceptable forms of payment are credit/debit card. I understand the cost of these tests may increase in the future without prior notice. I understand that insurance may not cover direct-to-consumer testing and may not reimburse these charges or apply them towards a deductible because the tests are not ordered by a physician. I accept full responsibility for inquiring with my insurer in this regard. I understand that a specimen submitted by me, or my child, will only be used to provides results for the test(s) mentioned above, and that no tests other than those authorized above will be performed on such specimen. I further understand that the specimen provided will be destroyed at the end of the testing process, or not more than sixty (60) days after analysis unless I authorize the further storage for use in research purposes. I understand that I may revoke this authorization for continued storage at any time. I hereby release Incyte Diagnostics, the medical staff, and any other organization involved in this testing, and their agents from all liabilities, medical claims, or expenses that may arise from my participation, or any injury sustained during this testing. I understand it is my responsibility to share test results with my provider.

Payment is required before placing this order

Disclaimer:

Fees for direct to consumer testing shall not be refundable under any circumstances.

I agree to the terms of service

You are paying for the SARS-COV2 test. You will be charged USD $150

Enter your credit card information

*By clicking submit the patient gives authorization for test results and associated protected health information (PHI) to be sent via digital delivery methods including SMS text and email.