Complete Your Request

Request Summary

Requested Service
Chlamydia / Gonorrhea RNA Test
HIV 1 & 2 Ab Test
HSV 1 & 2 Ab (IgG) Test
Hepatitis B Surface Antigen Test
Hepatitis C Antibody Test
RPR Test
Lab testing fees	$146.27
Medical provider and platform fees	$54.76
Total:	$201.03

Complete the form below to submit your request. All fields are required.

1. Choose Testing Location

Enter your Zip Code or city to see a list of available Quest Diagnostics lab locations in your area.

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Your Selected Lab

2. Patient Demographic Information

First Name

Last Name

Confirm Email

Sex

Female

Male

Birth Date

Phone

Address (Line 1)

Address (Line 2)

City

State

Zip Code

3. Patient Health Information

Past Medical Problems (e.g. Asthma - if none, type "none")

Current Medications (if none, type "none")

Known Allergies (if none, type "none")

Are you pregnant?

Are you breastfeeding?

Yes

Reason for Lab Testing (detailed is better)

4. Confirm Request and Agree to Terms

Total Fees: $201.03

Total fees include the lab order, all lab fees, and a copy of the results.

After you submit your request, a licensed medical provider in your area will review your information. You will be notified by email when that provider has reviewed your request and, if appropriate, made care recommendations.

By checking this box, you indicate that you, as the patient or legal guardian of the patient, agree to the Terms of Service, Lab Testing Terms of Use, Privacy Policy and Consent to Telehealth.

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