MPISSC

PalaDX Patient Registration

Please register to provide proof of prior testing or vaccination. If you require a test on-site, please use this form to register for day-of testing.
How will you be sharing your information?

I have proof of vaccination or a negative COVID-19 test result to upload. I require on-site testing.
Name *

Legal First Name Legal Last Name
Date of Birth *

Month Day Year
Have you received a COVID-19 PCR test within the last 48 hours? *

Yes No
Date of COVID-19 PCR test

Month Day Year
Upload a clear photo of your test result.

Cancel of
Have you received 2 doses of the COVID-19 vaccine? (1 dose for Janssen) *

Yes No
Date of First Dose

Month Day Year
Date of Second Dose

Month Day Year
If you received the Janssen vaccine, please enter the same date for First and Second dose.
Upload a clear photo of your vaccination record.

Cancel of
Gender *
Ethnicity *
Race *
Mobile Phone Number *
TO RECEIVE RESULTS YOU MUST PROVIDE A VALID MOBILE PHONE NUMBER. WE CANNOT SEND TEXT MESSAGES TO LANDLINES.
E-mail *
TO RECEIVE RESULTS YOU MUST PROVIDE A VALID E-MAIL ADDRESS.
Address *

Street Address

Street Address Line 2

City State

Zip Code Country
Do you have U.S. based health insurance? *

Yes No
Social Security Number or TIN *
IF YOU DO NOT HAVE A US GOVERNMENT ISSUED SOCIAL SECURITY NUMBER OR TAXPAYER ID NUMBER, PLEASE ENTER YOUR COUNTRY OF CITIZENSHIP.
Insurance Card

PLEASE UPLOAD A CLEAR PHOTO OF YOUR INSURANCE CARD.
Cancel of
Policy Number
VALID PHOTO ID REQUIRED.

Please do not upload anything other than a government issued Photo ID. Foreign passports are accepted. Please select "Other" for Type of ID and Issued By fields.
Type of ID *
SELECT OTHER FOR FOREIGN ISSUED IDENTIFICATION.
Photo ID Number *
Photo ID Expiration *

Month Day Year
IF YOUR PHOTO ID DOES NOT HAVE AN EXPIRATION DATE ENTER TODAY'S DATE.
Issued By *
SELECT OTHER FOR FOREIGN ISSUED IDENTIFICATION.
Photo ID *

YOU MUST UPLOAD A VALID AND LEGIBLE PHOTO ID.
Cancel of
Consent and Authorization *
Signature *
Site ID
Should be Empty:

PalaDX Patient Registration

VALID PHOTO ID REQUIRED.