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 <span style="color:#ff0000">*</span>

Patient Mobile Number <span style="color:#ff0000">*</span>

Sex *

Race *

Ethnicity *

Please enter your driver's license information OR your primary insurance number for identification purposes.

Please upload an image of your id and enter your drivers license number [If appropriate input is provided].

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

Drivers license number

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.

*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.
By clicking submit you agree to receive text messages from LabSender; Reply STOP to opt out; Reply HELP for help; Message frequency varies; Message and data rates may apply; Privacy Policy