Patient Registration
Primary Care Pharmacy
ID
*
Last Name
*
First Name
*
Date of Birth
*
Gender
*
Female
Male
Other
Cell Phone
Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Virgin Islands
Puerto Rico
Guam
AA
AE
AP
N/A
Zip
*
Email
*
The email address is a user name for the Patient Portal
Create Patient Portal Password
No insurance
State requires SSN or Driver's License for uninsured patients ordering COVID-19 test
Social Security Number
*
Driver's License
Insurance Company
*
Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Virgin Islands
Puerto Rico
Guam
AA
AE
AP
N/A
Zip
Membership ID
*
Group Number
Subscriber Relation
*
SELF
Spouse
Child
Subscriber Last Name
*
Subscriber First Name
*
Clinical Information
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Refuse to Answer
Race
*
Asian
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other Race
Refuse to Answer
Work in Healthcare w/ patient contact?
*
Yes
No
Unknown
Occupation or Job Title
*
Employer or School Name
*
Employer or School Street Address
*
Employer or School City
*
Employer or School State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Virgin Islands
Puerto Rico
Guam
AA
AE
AP
N/A
Employer or School Zip
*
Employer or School Phone
*
Currently have 1 or more symptoms?
*
Yes
No
Such as fever or chills, cough, shortness of breath, fatigue, muscle or body aches, headaches,
new loss of taste or smell, sore throat,congestion/runny nose, nausea/vomiting, and/or diarrhea?
When did your symptoms start?
*
(MM/DD/YYYY)
Are you currently pregnant?
*
Yes
No
N/A
Do you reside in a group setting?
*
Yes
No
Unknown
Is this your first test for COVID-19?
*
Yes
No
Unknown
Unknown
Other address you may reside at
*
Submit
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