Wake Toxicology Laboratory

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COVID-19 Test Request Form (Molecular RT-PCR and Antibody)

No appointments required for the test but testing might be cancelled based on Winter Weather conditions without further notice. Current lead time for results is 2-3 days. In Case of emergency find other local testing centers or healthcare providers. In case your insurance do not pay for the service provided, you are responsible for the charges.

Email *

Location *

First Name *

Last Name *

Date of Birth *

YYYY

Gender *

Female

Male

Prefer not to say

Race/Ethnicity *

Address *

Mobile Number *

Insurance Name *

Insurance ID *

Uninsured: Provide State ID or Driver License or SSN *

Date of Testing required *

YYYY

COVID Symptoms *

Shortness of breath/difficulty breathing

Fever, Cough, Headache, Sore Throat

New Loss of Taste or Smell

Repeated shaking with chills

Gastrointestinal (e.g nausea, vomiting, diarrhea)

Contact with COVID 19 tested positive person

Possible exposure to tested positive for COVID 19

Domestic and International Travel

Screening (Employment, work)

Other:

Required

Type of Test Required *

COVID 19 RT PCR -Swab Test

COVID 19 Antibody- Blood Test

Required

A copy of your responses will be emailed to the address you provided.

Submit

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