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Patient Registration

Please select the location you are at right now

First Name

Email

Last Name

Birthday

Cell Phone

Street Address

State

Zip code

City

Country

Reason for testing

Healthcare insurance carriers do not cover Covid-19 testing for travel purposes. Your test would require a payment. If you wish to continue, please select how quickly would you require your results.

Specify your symptoms. Select all that apply:

Chills (without fever) - R68.83

Contact with and (suspected) exposure to someone with Covid-19 - Z20.822

Cough, unspecified - R50.9

Fever, Unspecified - R50.9

Headache - R51

Muscle pain - R52

New loss of either taste or smell - R43.9

New loss of both taste and smell - R43.8

Shortness of breath or trouble breathing - R06.02

Sore throat - J02.9

Do you have a healthcare insurance?

Yes

No

What is your healthcare insurance carrier name?

Group Number

Policy Number/ Member ID

Upload front and back picture of your insurance card and front of your ID.

Upload File

Upload supported file (Max 15MB)

I declare that the info I’ve provided is accurate & complete. I authorize Rapid Response Physicians and its associates to contact me for any additional information.

Your Signature

Thank you for submitting! You should receive a patient portal link via email shortly.

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