COVID-19 TESTING REGISTRATION

Please complete the form below to register online for COVID-19 testing.

If you would prefer to register for an appointment by phone, please call Clinical Pathology Laboratories (CPL) at 702-795-4932. This phone line is open Monday through Friday, from 8 a.m. to 5 p.m. CPL has partnered with UMC and Clark County to further expand
our testing capacity at this location.

To expedite the registration process, please enter your name and date of birth exactly as they appear on your ID.

You must be 18 or older to register.

PATIENT INFORMATION
Last Name: * First Name: *
Date of Birth: * MM/DD/YYYY Phone #: *
Email: * SSN/Unique Identifier: * 9 digits only
Address 1: * Address 2:
City: * State: *
Zip Code: * Country:
Sex: * Race: *
Employee ID#: Occupation:
Primary Language:
Employer Name: Employer ID#:
 
EMERGENCY CONTACT
Contact Name: Relationship:
Phone:
 
COVERAGE
Primary Insurance
Name of Insurance: * Group #: *
Policy Holder Name: * Insurance Type: *
Policy Holder ID: * Policy Holder Date of Birth: * MM/DD/YYYY
Patient Relation to Policy Holder: *
 
INFORMED CONSENT

Please read the “Informed Consent for COVID-19 Diagnostic Testing” document. Clicking this link will open the document in a separate browser tab.

Acknowledgment