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*

MaleFemale
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*

American IndianAfrican AmericanAsianPacific IslanderCaucasianHispanicOther
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.
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*

Clear
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