Cervi-Guard Patient Registration Form

Complete this form to ensure that our lab can provide test results to the patient.

First and Last Name*: Enter the patient's first and last name. If this test is for someone else, use their name.
Email*: You will be asked to verify your email address at the end of this process.
Mobile Phone & C. Code: If you wish to receive text message notification of your test results, enter your mobile number here. You will be asked to verify it at the end
Date of Birth:
Home Address, City, State, ZIP*: You must provide a home address to the lab.
Home Address*:
City*:
State*:
ZIP*:
Kit ID*: Please locate the "REF" ID on the side of your test kit box and enter below Re-enter Test Kit ID*:

Where do I find my Test Kit ID? ▶

Re-enter Test Kit ID*:
Now for some risk assessment questions
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Are you age 18 or over?*:
Min 5 characters. Max 100 characters.
Have you ever smoked cigarettes?*:
Are you regularly exposed to secondhand tobacco smoke?*:
At what age did you first have sexual intercourse?*:
How many lifetime sexual partners have you had?*:
To your knowledge has your current or most recent long-term partner had many previous sexual partners?*:
Have you used oral contraceptives (birth control pills)?*:
How many full term pregnancies have you had?:
Do you have a condition that weakens your immune system?*:
Have you ever been diagnosed with a sexually transmitted infection (STI)?*:
Do you have a first degree relative (mother or sister) who has had cervical cancer?*:
Min 5 characters. Max 100 characters.
When was your last cervical cancer screening (pap smear and/or HPV test)?*:
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