TubiLab | COVID Test Pre-Registration

After you fill in and submit this COVID testing registration form, please visit any one of our Tubi Test Sites to complete your test. You can find a location using the TubiTracker app. Thank you for choosing to stay safe.

COVID Test Pre-Registration

Test Type

Rapid

PCR

Both

Birth Date

Used for SMS text messaging to send login info for results

Insurance

Yes

Covid-19 Testing Questionaire (Required)

First Test

Yes

Unknown

Employed in Healthcare

Yes

Unknown

Exposed to COVID

Yes

Unknown

Pregnant

Yes

Unknown

Resident in a congregate care setting

Yes

Unknown

Any Symptoms? (as defined by CDC)

Yes

Unknown

PATIENT CONSENT FOR TESTING

The information I have provided on this form is accurate.I authorize TubiLabs( a DBA of Heritage Labs) to release the results of this test to my treating provider or facility. I hereby authorize my insurance or other payment to pay TubiLabs(a DBA of Heritage Labs) for services I receive. I am aware that I am responsible for all copays and deductibles not covered by insurance or other payors. I acknowledge that my sample and/extracted nucleic acids (DNA&/orRNA)may be kept and stored and that the sample may be used in the future for laboratory quality control and/or validation purposes.