International Travel Form

International Travel Testing Registration
Please contact us at (704) 412-3612 if you have any questions.

If you are looking for our employer/event international travel testing please select the option above.

Click "Start" below to begin registering for an international travel test.

International Travel Form
Name

First NameLast Name
Date Of Birth

MonthDayYear
Gender
Passport Number
This a 9 digit number for US and is found on the information page of your passport.
Passport Country of Issuance

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Passport Date of Issuance

MonthDayYear
Nationality

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race and Ethnicity

Other
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
COUNTY of Home Address
Travelers from outside the United States should put their home country here
Email

Confirmation EmailPlease enter your email address.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Test Date

MonthDayYear
Test Time

Hour Minutes

AM/PM Option
Anticipated Travel Date

MonthDayYear
Upload An Image of Your Test Result

Cancelof
Test Type

Test	Description	Price
ID NOW	The ID NOW Test uses Isothermal Nucleic Acid Amplification Technology. The ID NOW is a molecular test.	$150
BinaxNOW	The BinaxNOW Test utilizes lateral flow technology to detect if there are proteins from SARS-CoV-2. The BinaxNOW is an antigen test.	$50
Accula	The Accula SARS-CoV-2 Test performed on the Accula Dock is a molecular in vitro diagnostic test utilizing polymerase chain reaction and lateral flow technologies for the qualitative, visual detection of the coronavirus SARS-CoV-2 viral RNA.	$175

I, the undersigned testing participant, acknowledge that I have been given an opportunity to review a copy of the HIPAA PRIVACY NOTICE.
Signature
Specimen Collection Date

MonthDayYear
Date
Result Date

MonthDayYear
Date
Test Information
Specimen Type
Lab Name
Lab Address
Lab Phone Number
Lab Director
NPI
Price
Multiplier
Total
Coupon Code

International Travel Testing Registration