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Covid 19 Rapid Antigen Tests
Onboarding Form
Requested Antigent Test(s)
lifeSign Status Covid 19 + Flu A/B Rapid Antigent Test
InBios Covid 19 Rapid Antigent Test
Amount of lifeSign Boxes (Box Contains 25 Tests, $25 per test, $625 per box)
Amount of InBios Boxes (Box Contains 50 Tests, $15 per test, $750 per box)
Company Legal Name
DBA, if applicable
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Main Phone Number
Shipping Address, if different than above
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Country
Customer Typer (check those that apply):
Hosptial
Municipalities
Schools
Colleges
Urgent Care
Nursing Home/LTC
Physician Practice
Business
Other
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