Your Info
Medical
Tests
Consent
Payment
Done

Personal Information

Your information is protected under HIPAA. Fields marked * are required.

First Name *

Middle Initial

Last Name *

Date of Birth *

Biological Sex * Used to apply correct reference ranges

Contact

Email Address * Results and receipts will be sent here

Mobile Phone * For SMS notifications when results are ready

Street Address

City

State

ZIP

Emergency Contact

Emergency Contact Name

Emergency Contact Phone

Returning Patient?

Have you visited before?

First visit

I've been here before

Medical Background

This helps us apply accurate reference ranges and flag any relevant interactions.

Fasting Status

Current fasting status

Fasting (8+ hrs)

Not fasting

Under 8 hrs

Some tests (glucose, lipids) require 8–12 hours of fasting for accurate results.

Current Medications

List any medications or supplements Include prescription drugs, OTC medications, vitamins, and supplements

Relevant History

Check all medical history that applies to you

Diabetes or pre-diabetes Thyroid disorder Cardiovascular disease or high cholesterol Hormone replacement therapy (HRT) Autoimmune condition Currently pregnant or breastfeeding

Additional Notes

Anything else you'd like the lab to know?

Select Your Tests

Choose one or more panels. Panels can be combined in a single visit. No referral needed.

Order Summary

Consent & Authorization

Please read and sign each consent below. Your signature is required to proceed.

HIPAA Notice of Privacy Practices

Rapid Testing Lab ("the Lab") is committed to protecting your health information. This notice describes how medical information about you may be used and disclosed. We may use your information for treatment purposes, for payment processing, and for healthcare operations. We will not sell your information to third parties. You have the right to access, amend, and request restrictions on your information. The Lab maintains administrative, physical, and technical safeguards including 256-bit encryption at rest and TLS 1.3 in transit. For questions, contact our Privacy Officer at 435-254-2427.

I acknowledge receipt of the HIPAA Notice of Privacy Practices

Consent to Test

I authorize Rapid Testing Lab to collect biological samples (blood, urine, saliva, or other specimens as appropriate) and perform the tests I have selected. I understand that testing involves venipuncture or other collection methods and carries minimal risk. Results will be provided directly to me. No physician order is required for these self-pay direct-access tests. I acknowledge results are for informational purposes and I am encouraged to discuss abnormal results with a licensed healthcare provider.

I consent to the collection and testing of my biological samples

Electronic Results Delivery

I authorize Rapid Testing Lab to deliver my test results electronically via email and/or SMS to the contact information I provided. Results will be sent via a secure, encrypted link. I understand that electronic delivery carries inherent risks if my devices or accounts are compromised. Results will be retained for a minimum of 7 years per CLIA regulations and accessible through the patient portal during that period.

I consent to receive results electronically

Digital Signature

Sign below * (required)

Use mouse or touch to sign. Press Delete to clear.

By signing, you confirm you have read and agree to all consents above. Date:

Payment

All payments are processed securely through Square. We accept credit, debit, and HSA/FSA cards.

Card Details

Cardholder Name *

Card Number *

VISA

16-digit number on the front of your card

Expiry *

CVV *

Billing ZIP

Payments processed by Square · 256-bit encrypted · No card data stored by RTL

Email me a receipt Notify me by SMS when results are ready

You're All Set!

Registration confirmed. You'll receive a confirmation email shortly. Walk in when you're ready — no wait required.

🔬

Accession #

RTL-2026-00142

⏱

Est. Results

Same day – 24 hrs

📧

Sent to

your@email.com

Next steps: Walk in to our St. George location. Bring this confirmation or give us your name at the front desk. For blood tests, keep your fasting status in mind. Results will be sent to your email via a secure link.

Walk-in ready No referral needed HIPAA protected CLIA certified