www.iopenworld.com
Open in
urlscan Pro
50.62.136.145
Public Scan
Submitted URL: https://u23924848.ct.sendgrid.net/ls/click?upn=Dia9RnRL-2FEoUQhuxlZ-2BqSpob6nee-2Fl4vr8sCjDGgk3N1D91GfXrTbGJH0jPSuWPeZ2iCfEyKyH-2B...
Effective URL: https://www.iopenworld.com/university-landing-page/
Submission Tags: falconsandbox
Submission: On February 20 via api from US — Scanned from DE
Effective URL: https://www.iopenworld.com/university-landing-page/
Submission Tags: falconsandbox
Submission: On February 20 via api from US — Scanned from DE
Form analysis 3 forms found in the DOM
POST /university-landing-page/
<form id="wpforms-form-1528" class="wpforms-validate wpforms-form wpforms-ajax-form" data-formid="1528" method="post" enctype="multipart/form-data" action="/university-landing-page/" data-token="9281851a1060644023e27a29123b34b1"
novalidate="novalidate"><noscript class="wpforms-error-noscript">Please enable JavaScript in your browser to complete this form.</noscript>
<div class="wpforms-field-container">
<div id="wpforms-1528-field_0-container" class="wpforms-field wpforms-field-name" data-field-id="0"><label class="wpforms-field-label" for="wpforms-1528-field_0">Name <span class="wpforms-required-label">*</span></label>
<div class="wpforms-field-row wpforms-field-medium">
<div class="wpforms-field-row-block wpforms-first wpforms-one-half"><input type="text" id="wpforms-1528-field_0" class="wpforms-field-name-first wpforms-field-required" name="wpforms[fields][0][first]" required=""><label
for="wpforms-1528-field_0" class="wpforms-field-sublabel after ">First</label></div>
<div class="wpforms-field-row-block wpforms-one-half"><input type="text" id="wpforms-1528-field_0-last" class="wpforms-field-name-last wpforms-field-required" name="wpforms[fields][0][last]" required=""><label for="wpforms-1528-field_0-last"
class="wpforms-field-sublabel after ">Last</label></div>
</div>
</div>
<div id="wpforms-1528-field_1-container" class="wpforms-field wpforms-field-email" data-field-id="1"><label class="wpforms-field-label" for="wpforms-1528-field_1">Email <span class="wpforms-required-label">*</span></label><input type="email"
id="wpforms-1528-field_1" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][1]" required=""></div>
<div id="wpforms-1528-field_3-container" class="wpforms-field wpforms-field-number" data-field-id="3"><label class="wpforms-field-label" for="wpforms-1528-field_3">Phone Number <span class="wpforms-required-label">*</span></label><input
type="number" pattern="\d*" id="wpforms-1528-field_3" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][3]" required=""></div>
<div id="wpforms-1528-field_6-container" class="wpforms-field wpforms-field-number-slider" data-field-id="6"><label class="wpforms-field-label" for="wpforms-1528-field_6">How many FDA Approved Tests do you need? </label>
<input type="range" id="wpforms-1528-field_6" class="wpforms-field-medium" name="wpforms[fields][6]" value="2" min="1" max="10000" step="1">
<div class="wpforms-field-number-slider-hint" data-hint="Selected Value: {value}"> Selected Value: <b>2</b></div>
</div>
</div>
<div class="wpforms-submit-container"><input type="hidden" name="wpforms[id]" value="1528"><input type="hidden" name="wpforms[author]" value="9"><input type="hidden" name="wpforms[post_id]" value="1728"><button type="submit" name="wpforms[submit]"
id="wpforms-submit-1528" class="wpforms-submit" data-alt-text="Sending..." data-submit-text="Submit" aria-live="assertive" value="wpforms-submit">Submit</button><img
src="https://www.iopenworld.com/wp-content/plugins/wpforms/assets/images/submit-spin.svg" class="wpforms-submit-spinner" style="display: none;" width="26" height="26" alt="Loading"></div>
</form>POST /university-landing-page/
<form id="wpforms-form-2611" class="wpforms-validate wpforms-form wpforms-ajax-form" data-formid="2611" method="post" enctype="multipart/form-data" action="/university-landing-page/" data-token="ca7436599375b9edfaca46373b32f936"
novalidate="novalidate"><noscript class="wpforms-error-noscript">Please enable JavaScript in your browser to complete this form.</noscript>
<div class="wpforms-field-container">
<div id="wpforms-2611-field_1-container" class="wpforms-field wpforms-field-email" data-field-id="1"><label class="wpforms-field-label wpforms-label-hide" for="wpforms-2611-field_1">Email <span
class="wpforms-required-label">*</span></label><input type="email" id="wpforms-2611-field_1" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][1]" placeholder="Email Address" required=""></div>
</div>
<div class="wpforms-submit-container"><input type="hidden" name="wpforms[id]" value="2611"><input type="hidden" name="wpforms[author]" value="9"><input type="hidden" name="wpforms[post_id]" value="1728"><button type="submit" name="wpforms[submit]"
id="wpforms-submit-2611" class="wpforms-submit" data-alt-text="Sending..." data-submit-text="Submit" aria-live="assertive" value="wpforms-submit">Submit</button><img
src="https://www.iopenworld.com/wp-content/plugins/wpforms/assets/images/submit-spin.svg" class="wpforms-submit-spinner" style="display: none;" width="26" height="26" alt="Loading"></div>
</form>POST /university-landing-page/#gf_1
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_1" id="gform_1" action="/university-landing-page/#gf_1" novalidate=""><input id="partial_entry_id_1" class="partial_entry_id" type="hidden" name="partial_entry_id"
value="pending" data-form_id="1">
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div id="gf_progressbar_wrapper_1" class="gf_progressbar_wrapper">
<p class="gf_progressbar_title">Step <span class="gf_step_current_page">1</span> of <span class="gf_step_page_count">5</span>
</p>
<div class="gf_progressbar gf_progressbar_blue" aria-hidden="true">
<div class="gf_progressbar_percentage percentbar_blue percentbar_20" style="width:20%;"><span>20%</span></div>
</div>
</div>
<div class="gform_body gform-body">
<div id="gform_page_1_1" class="gform_page">
<div class="gform_page_fields">
<div id="gform_fields_1" class="gform_fields top_label form_sublabel_below description_below">
<div id="field_1_5" class="gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_5">
<h2>Request at-home tests</h2>
<p>Insurers cover up to 8 at-home COVID-19 tests per person monthly. All fields are required.</p>
</div>
<fieldset id="field_1_1" class="gfield has-border-bottom gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_1">
<legend class="gfield_label">Do you carry health insurance?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_1">
<div class="gchoice gchoice_1_1_0">
<input class="gfield-choice-input" name="input_1" type="radio" value="Yes" id="choice_1_1_0" onchange="gformToggleRadioOther( this )" aria-describedby="gfield_description_1_1">
<label for="choice_1_1_0" id="label_1_1_0">Yes</label>
</div>
<div class="gchoice gchoice_1_1_1">
<input class="gfield-choice-input" name="input_1" type="radio" value="No" id="choice_1_1_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_1_1" id="label_1_1_1">No</label>
</div>
</div>
</div>
<div class="gfield_description" id="gfield_description_1_1">Note: This program only applies to those persons who carry health insurance<br></div>
</fieldset>
<fieldset id="field_1_3" class="gfield gfield--width-full has-border-bottom gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_3">
<legend class="gfield_label">Do you want express of ground shipping?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_3">
<div class="gchoice gchoice_1_3_0">
<input class="gfield-choice-input" name="input_3" type="radio" value="UPS Ground (7-10 Days) FREE" id="choice_1_3_0" onchange="gformToggleRadioOther( this )" aria-describedby="gfield_description_1_3">
<label for="choice_1_3_0" id="label_1_3_0">UPS Ground (7-10 Days) FREE</label>
</div>
<div class="gchoice gchoice_1_3_1">
<input class="gfield-choice-input" name="input_3" type="radio" value="Express shipping & handling 2-3 day - $29.99" id="choice_1_3_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_3_1" id="label_1_3_1">Express shipping & handling 2-3 day - $29.99</label>
</div>
</div>
</div>
<div class="gfield_description" id="gfield_description_1_3">Note: If you order less than 8 kits shipping charges apply.</div>
</fieldset>
<div id="field_1_4" class="gfield gfield--width-full has-border-bottom text-selectfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible" data-js-reload="field_1_4"><label class="gfield_label"
for="input_1_4">Tests</label>
<div class="ginput_container ginput_container_select"><select name="input_4" id="input_1_4" class="large gfield_select" aria-describedby="gfield_description_1_4" aria-invalid="false">
<option value="8 Tests">8 Tests</option>
<option value="2 Tests">2 Tests</option>
<option value="4 Tests">4 Tests</option>
<option value="6 Tests">6 Tests</option>
</select></div>
<div class="gfield_description" id="gfield_description_1_4">Minimum order of 2 tests. You will receive 2 tests per pack. Anything less than 8 tests will have a shipping charge applied. </div>
</div>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_next_button_1_10" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_2" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_1_2" class="gform_fields top_label form_sublabel_below description_below">
<div id="field_1_6" class="gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_6">
<h2>Who are the tests for?</h2>
<p>Insurers cover up to 8 at-home COVID-19 tests per person monthly. All fields are required.</p>
</div>
<fieldset id="field_1_7" class="gfield gfield--width-full has-border-bottom gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_7">
<legend class="gfield_label">Are you submitting the request for yourself of someone else?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_7">
<div class="gchoice gchoice_1_7_0">
<input class="gfield-choice-input" name="input_7" type="radio" value="Myself" id="choice_1_7_0" onchange="gformToggleRadioOther( this )">
<label for="choice_1_7_0" id="label_1_7_0">Myself</label>
</div>
<div class="gchoice gchoice_1_7_1">
<input class="gfield-choice-input" name="input_7" type="radio" value="Someone else" id="choice_1_7_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_7_1" id="label_1_7_1">Someone else</label>
</div>
</div>
</div>
</fieldset>
<div id="field_1_37" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_37"><label class="gfield_label" for="input_1_37">Reason for
Testing<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_37" id="input_1_37" type="text" value="" class="large" aria-describedby="gfield_description_1_37" aria-required="true" aria-invalid="false"> </div>
<div class="gfield_description" id="gfield_description_1_37">e.g. high-risk settings, possible symptoms, large gatherings with possible exposure.</div>
</div>
<fieldset id="field_1_14" class="gfield gfield--width-full label-form gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible" data-js-reload="field_1_14">
<legend class="gfield_label gfield_label_before_complex">Address Recognized by your Insurance Company<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
<div class="gfield_description" id="gfield_description_1_14">First Name and Last on record with your Insurance Company must match exactly.</div>
<div class="ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name" id="input_1_14">
<span id="input_1_14_3_container" class="name_first">
<label for="input_1_14_3">First Name</label>
<input type="text" name="input_14.3" id="input_1_14_3" value="" aria-required="true" aria-describedby="gfield_description_1_14">
</span>
<span id="input_1_14_6_container" class="name_last">
<label for="input_1_14_6">Last Name</label>
<input type="text" name="input_14.6" id="input_1_14_6" value="" aria-required="true">
</span>
</div>
</fieldset>
<div id="field_1_15" class="gfield gfield--width-full has-border-bottom dob-full label-form gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible" data-js-reload="field_1_15"><label
class="gfield_label" for="input_1_15">Date of birth<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_15" id="input_1_15" type="text" value="" class="datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="mm/dd/yyyy" aria-describedby="input_1_15_date_format"
aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://www.iopenworld.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_1_15_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_1_15" class="gform_hidden" value="https://www.iopenworld.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<fieldset id="field_1_8" class="gfield gfield--width-full gfield_contains_required field_sublabel_above field_description_below hidden_label gfield_visibility_visible" data-js-reload="field_1_8">
<legend class="gfield_label gfield_label_before_complex">Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
<div class="ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address" id="input_1_8">
<span class="ginput_full address_line_1 ginput_address_line_1" id="input_1_8_1_container">
<label for="input_1_8_1" id="input_1_8_1_label">Street Address</label>
<input type="text" name="input_8.1" id="input_1_8_1" value="" aria-required="true" aria-describedby="gfield_description_1_8">
</span><span class="ginput_full address_line_2 ginput_address_line_2" id="input_1_8_2_container">
<label for="input_1_8_2" id="input_1_8_2_label">Unit, apartment etc (optional)</label>
<input type="text" name="input_8.2" id="input_1_8_2" value="" aria-required="false">
</span><span class="ginput_left address_city ginput_address_city" id="input_1_8_3_container">
<label for="input_1_8_3" id="input_1_8_3_label">City</label>
<input type="text" name="input_8.3" id="input_1_8_3" value="" aria-required="true">
</span><span class="ginput_right address_state ginput_address_state" id="input_1_8_4_container">
<label for="input_1_8_4" id="input_1_8_4_label">State</label>
<select name="input_8.4" id="input_1_8_4" aria-required="true">
<option value="" selected="selected"></option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="American Samoa">American Samoa</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Guam">Guam</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="U.S. Virgin Islands">U.S. Virgin Islands</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Europe">Armed Forces Europe</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
</select>
</span><span class="ginput_left address_zip ginput_address_zip" id="input_1_8_5_container">
<label for="input_1_8_5" id="input_1_8_5_label">ZIP Code</label>
<input type="text" name="input_8.5" id="input_1_8_5" value="" aria-required="true">
</span><input type="hidden" class="gform_hidden" name="input_8.6" id="input_1_8_6" value="United States">
<div class="gf_clear gf_clear_complex"></div>
</div>
<div class="gfield_description" id="gfield_description_1_8">This is the address that your insurance company has on record for you. Could be your address or possibly your spouse/parent's address.</div>
</fieldset>
<div id="field_1_18" class="gfield gfield--width-half label-form gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_18"><label class="gfield_label" for="input_1_18">Email
address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_18" id="input_1_18" type="email" value="" class="large" aria-required="true" aria-invalid="false">
</div>
</div>
<div id="field_1_19" class="gfield gfield--width-half label-form gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_19"><label class="gfield_label"
for="input_1_19">Mobile Number<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_19" id="input_1_19" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_1_21" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("1"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("1"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_21"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("3"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("3"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_3" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_1_3" class="gform_fields top_label form_sublabel_below description_below">
<div id="field_1_22" class="gfield gfield--width-full form-data-table gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_22">
<h2>Preview Submission</h2>
<table>
<tbody>
<tr>
<td>Do you carry health insurance?</td>
<td class="field_1"></td>
</tr>
<tr>
<td>Do you want express of ground shipping?</td>
<td class="field_3"></td>
</tr>
<tr>
<td>Tests</td>
<td class="field_4"></td>
</tr>
<tr>
<td> Are you submitting the request for yourself of someone else?</td>
<td class="field_7"></td>
</tr>
<tr>
<td> Reason for Testing</td>
<td class="field_37"></td>
</tr>
<tr>
<td> First Name </td>
<td class="input_1_14_3"></td>
</tr>
<tr>
<td> Last Name </td>
<td class="input_1_14_6"></td>
</tr>
<tr>
<td> Date of birth (MM/DD/YYYY) </td>
<td class="input_1_15"></td>
</tr>
<tr>
<td> Address </td>
<td class="field_17">
<span class="st_address input_1_8_1"></span>,<span class="unit_apart input_1_8_2"></span><br>
<span class="city input_1_8_3"></span>, <span class="state input_1_8_4"></span><br>
<span class="zipcode input_1_8_5"></span><br>
</td>
</tr>
<tr>
<td> Email address</td>
<td class="field_18"></td>
</tr>
<tr>
<td> Mobile Number</td>
<td class="field_19"></td>
</tr>
</tbody>
</table>
</div>
<fieldset id="field_1_16" class="gfield gfield--width-full assigned-birth gf_list_inline gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible" data-js-reload="field_1_16">
<legend class="gfield_label">Sex assigned at birth<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
<div class="gfield_description" id="gfield_description_1_16">
</div>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_1_16">
<div class="gchoice gchoice_1_16_0">
<input class="gfield-choice-input" name="input_16" type="radio" value="Female" id="choice_1_16_0" onchange="gformToggleRadioOther( this )" aria-describedby="gfield_description_1_16">
<label for="choice_1_16_0" id="label_1_16_0">Female</label>
</div>
<div class="gchoice gchoice_1_16_1">
<input class="gfield-choice-input" name="input_16" type="radio" value="Male" id="choice_1_16_1" onchange="gformToggleRadioOther( this )">
<label for="choice_1_16_1" id="label_1_16_1">Male</label>
</div>
</div>
</div>
</fieldset>
<div id="field_1_17" class="gfield gfield--width-full gfield_html gfield_html_formatted field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_17"> <small>Note: Required fields*</small></div>
<div id="field_1_36" class="gfield gfield--width-third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_36"><label class="gfield_label" for="input_1_36">Insurance
Carrier<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_36" id="input_1_36" class="large gfield_select" aria-required="true" aria-invalid="false">
<option value="Aetna">Aetna</option>
<option value="Cigna">Cigna</option>
<option value="Humana">Humana</option>
<option value="United">United</option>
<option value="Blue Cross Blue Shield">Blue Cross Blue Shield</option>
<option value="Mutual of Omaha">Mutual of Omaha</option>
<option value="TRUSTMARK">TRUSTMARK</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="field_1_35" class="gfield gfield--width-third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_35"><label class="gfield_label" for="input_1_35">Insurance
Number<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_35" id="input_1_35" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_1_34" class="gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_34"><label class="gfield_label" for="input_1_34">Insurance Group Number</label>
<div class="ginput_container ginput_container_text"><input name="input_34" id="input_1_34" type="text" value="" class="large" aria-describedby="gfield_description_1_34" aria-invalid="false"> </div>
<div class="gfield_description" id="gfield_description_1_34">*If applicable</div>
</div>
<fieldset id="field_1_24" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_24">
<legend class="gfield_label gfield_label_before_complex">Shipping Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
<div class="ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address" id="input_1_24">
<span class="ginput_full address_line_1 ginput_address_line_1" id="input_1_24_1_container">
<input type="text" name="input_24.1" id="input_1_24_1" value="" aria-required="true">
<label for="input_1_24_1" id="input_1_24_1_label">Street Address</label>
</span><span class="ginput_full address_line_2 ginput_address_line_2" id="input_1_24_2_container">
<input type="text" name="input_24.2" id="input_1_24_2" value="" aria-required="false">
<label for="input_1_24_2" id="input_1_24_2_label">Address Line 2</label>
</span><span class="ginput_left address_city ginput_address_city" id="input_1_24_3_container">
<input type="text" name="input_24.3" id="input_1_24_3" value="" aria-required="true">
<label for="input_1_24_3" id="input_1_24_3_label">City</label>
</span><span class="ginput_right address_state ginput_address_state" id="input_1_24_4_container">
<input type="text" name="input_24.4" id="input_1_24_4" value="" aria-required="true">
<label for="input_1_24_4" id="input_1_24_4_label">State / Province / Region</label>
</span><span class="ginput_left address_zip ginput_address_zip" id="input_1_24_5_container">
<input type="text" name="input_24.5" id="input_1_24_5" value="" aria-required="true">
<label for="input_1_24_5" id="input_1_24_5_label">ZIP / Postal Code</label>
</span><span class="ginput_right address_country ginput_address_country" id="input_1_24_6_container">
<select name="input_24.6" id="input_1_24_6" aria-required="true">
<option value="" selected="selected"></option>
<option value="Afghanistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bonaire, Sint Eustatius and Saba">Bonaire, Sint Eustatius and Saba</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cabo Verde">Cabo Verde</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos Islands">Cocos Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curaçao">Curaçao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czechia">Czechia</option>
<option value="Côte d'Ivoire">Côte d'Ivoire</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Eswatini">Eswatini</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands">Falkland Islands</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories">French Southern Territories</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See">Holy See</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option>
<option value="Korea, Republic of">Korea, Republic of</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia">Micronesia</option>
<option value="Moldova">Moldova</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="North Macedonia">North Macedonia</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestine, State of">Palestine, State of</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Romania">Romania</option>
<option value="Russian Federation">Russian Federation</option>
<option value="Rwanda">Rwanda</option>
<option value="Réunion">Réunion</option>
<option value="Saint Barthélemy">Saint Barthélemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin">Saint Martin</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten">Sint Maarten</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Georgia and the South Sandwich Islands">South Georgia and the South Sandwich Islands</option>
<option value="South Sudan">South Sudan</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria Arab Republic">Syria Arab Republic</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania, the United Republic of">Tanzania, the United Republic of</option>
<option value="Thailand">Thailand</option>
<option value="Timor-Leste">Timor-Leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Türkiye">Türkiye</option>
<option value="US Minor Outlying Islands">US Minor Outlying Islands</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United States">United States</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Venezuela">Venezuela</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands, British">Virgin Islands, British</option>
<option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
<option value="Åland Islands">Åland Islands</option>
</select>
<label for="input_1_24_6" id="input_1_24_6_label">Country</label>
</span>
<div class="gf_clear gf_clear_complex"></div>
</div>
</fieldset>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_1_25" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_25"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("4"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("4"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_4" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_1_4" class="gform_fields top_label form_sublabel_below description_below">
<div id="field_1_26" class="gfield gfield--width-full form-data-table gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_26">
<h2>Preview Submission</h2>
<table>
<tbody>
<tr>
<td>Do you carry health insurance?</td>
<td class="field_1"></td>
</tr>
<tr>
<td>Do you wont express of ground shipping?</td>
<td class="field_3"></td>
</tr>
<tr>
<td>Tests</td>
<td class="field_4"></td>
</tr>
<tr>
<td> Are you submitting the request for yourself of someone else?</td>
<td class="field_7"></td>
</tr>
<tr>
<td> Reason for Testing</td>
<td class="field_37"></td>
</tr>
<tr>
<td> First Name </td>
<td class="input_1_14_3"></td>
</tr>
<tr>
<td> Last Name </td>
<td class="input_1_14_6"></td>
</tr>
<tr>
<td> Date of birth (MM/DD/YYYY) </td>
<td class="input_1_15"></td>
</tr>
<tr>
<td> Address </td>
<td class="field_17">
<span class="st_address input_1_8_1"></span>,<span class="unit_apart input_1_8_2"></span><br>
<span class="city input_1_8_3"></span>, <span class="state input_1_8_4"></span><br>
<span class="zipcode input_1_8_5"></span><br>
</td>
</tr>
<tr>
<td> Email address</td>
<td class="field_18"></td>
</tr>
<tr>
<td> Mobile Number</td>
<td class="field_19"></td>
</tr>
<tr>
<td> Sex assigned at birth </td>
<td class="field_16"></td>
</tr>
<tr>
<td> Insurance Carrier </td>
<td class="field_36"></td>
</tr>
<tr>
<td> Insurance Number </td>
<td class="field_35"></td>
</tr>
<tr>
<td> Insurance Group Number </td>
<td class="field_34"></td>
</tr>
<tr>
<td> Shipping Address </td>
<td class="field_24">
<span class="st_address input_1_24_1"></span>,<span class="unit_apart input_1_24_2"></span><br>
<span class="city input_1_24_3"></span>, <span class="state input_1_24_4"></span><br>
<span class="zipcode input_1_24_5"></span><br>
<span class="country input_1_24_6"></span>
</td>
</tr>
</tbody>
</table>
</div>
<div id="field_1_30" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_30"><label class="gfield_label" for="input_1_30">Add your
insurance card image<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_fileupload"><input type="hidden" name="MAX_FILE_SIZE" value="268435456"><input name="input_30" id="input_1_30" type="file" class="large" aria-describedby="gfield_upload_rules_1_30"
onchange="javascript:gformValidateFileSize( this, 268435456 );"><span class="gform_fileupload_rules" id="gfield_upload_rules_1_30">Accepted file types: jpg, jpeg, png, hvec, Max. file size: 256 MB.</span>
<div class="validation_message validation_message--hidden-on-empty" id="live_validation_message_1_30"></div>
</div>
</div>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_previous_button_1_42" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("3"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("3"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_42"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("5"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("5"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_5" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_1_5" class="gform_fields top_label form_sublabel_below description_below">
<div id="field_1_43" class="gfield gfield--width-full form-data-table gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_43">
<h2>Preview Submission</h2>
<table>
<tbody>
<tr>
<td>Do you carry health insurance?</td>
<td class="field_1"></td>
</tr>
<tr>
<td>Do you wont express of ground shipping?</td>
<td class="field_3"></td>
</tr>
<tr>
<td>Tests</td>
<td class="field_4"></td>
</tr>
<tr>
<td> Are you submitting the request for yourself of someone else?</td>
<td class="field_7"></td>
</tr>
<tr>
<td> Reason for Testing</td>
<td class="field_37"></td>
</tr>
<tr>
<td> First Name </td>
<td class="input_1_14_3"></td>
</tr>
<tr>
<td> Last Name </td>
<td class="input_1_14_6"></td>
</tr>
<tr>
<td> Date of birth (MM/DD/YYYY) </td>
<td class="input_1_15"></td>
</tr>
<tr>
<td> Sex assigned at birth </td>
<td class="field_16"></td>
</tr>
<tr>
<td> Insurance Carrier </td>
<td class="field_36"></td>
</tr>
<tr>
<td> Insurance Number </td>
<td class="field_35"></td>
</tr>
<tr>
<td> Insurance Group Number </td>
<td class="field_34"></td>
</tr>
<tr>
<td> Address </td>
<td class="field_17">
<span class="st_address input_1_8_1"></span>,<span class="unit_apart input_1_8_2"></span><br>
<span class="city input_1_8_3"></span>, <span class="state input_1_8_4"></span><br>
<span class="zipcode input_1_8_5"></span><br>
</td>
</tr>
<tr>
<td> Email address</td>
<td class="field_18"></td>
</tr>
<tr>
<td> Mobile Number</td>
<td class="field_19"></td>
</tr>
<tr>
<td> Shipping Address </td>
<td class="field_24">
<span class="st_address input_1_24_1"></span>,<span class="unit_apart input_1_24_2"></span><br>
<span class="city input_1_24_3"></span>, <span class="state input_1_24_4"></span><br>
<span class="zipcode input_1_24_5"></span><br>
<span class="country input_1_24_6"></span>
</td>
</tr>
<tr>
<td> Your Insurance Card </td>
<td class="field_30"></td>
</tr>
</tbody>
</table>
</div>
<fieldset id="field_1_32" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_32">
<legend class="gfield_label gfield_label_before_complex">Consent<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
<div class="ginput_container ginput_container_consent"><input name="input_32.1" id="input_1_32_1" type="checkbox" value="1" aria-required="true" aria-invalid="false"> <label class="gfield_consent_label" for="input_1_32_1">I agree to the
privacy policy.</label><input type="hidden" name="input_32.2" value="I agree to the privacy policy." class="gform_hidden"><input type="hidden" name="input_32.3" value="1" class="gform_hidden"></div>
</fieldset>
</div>
</div>
<div class="gform_page_footer top_label"><input type="submit" id="gform_previous_button_1" class="gform_previous_button button" value="Previous"
onclick="if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} jQuery("#gform_1").trigger("submit",[true]); }">
<input type="hidden" name="affwp_action" value="affiliate_register"><input type="submit" id="gform_submit_button_1" class="gform_button button" value="Order Now"
onclick="if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} jQuery("#gform_1").trigger("submit",[true]); }">
<input type="hidden" name="gform_ajax" value="form_id=1&title=&description=&tabindex=0">
<input type="hidden" class="gform_hidden" name="is_submit_1" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="1">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_1"
value="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">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_1" id="gform_target_page_number_1" value="2">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_1" id="gform_source_page_number_1" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</div>
</div>
<input type="hidden" name="pum_form_popup_id" value="2587">
</form>Text Content
* Skip to main content * Skip to footer (202) 792-8022 * +1 (254) 876-0550 * Home * Notice of HIPAA Privacy Practices * Privacy Policy * News * +1 (254) 876-0550 * Sign Up UNIVERSITY LANDING PAGE ENSURE A COVID-FREE ENVIRONMENT! GET FDA APPROVED TEST KITS STARTING AT ONLY $4.80 RESULTS IN 15 MINUTES Order Now THE DYNAMIC APP THAT FOSTERS A COVID-FREE ENVIRONMENT iOpen is unlikely any other. We help venues across America from colleges to concert halls to wedding venues manage the challenges of real-time COVID testing on-demand 24/7. Seamlessly aggregate and report student, athletic, and faculty test results, individually or by the hundreds to school administration or by any designated person or department. Best on all – it’s FREE Seamlessly test University faculty, students on-campus or aboard along athletes individually or by the hundreds with centralized reporting. Increase capacities safely and provide confidence at entertainment and sporting events. Reinstate back-to-campus operations for all faculty safely and confidently with proactive testing on-demand with seamless reporting. Delegated dormitory managers can test report with confidence, on-demand 24/7. Screen all contractors who are performing work at or on the school campus. Centralized reporting of all University-related COVID testing for a balanced aggregated approach. No guesswork going forward – If new variants are discovered the testing protocol can be changed and deployed via the iOpen Administrators and schools can remain open without interruptions. Requiring all employers with 100 or more employees to ensure that their workforces are fully vaccinated and to impose mandatory weekly testing requirements for any employees that remain unvaccinated. The Administration is directing the Occupational Safety and Health Administration (OSHA) to issue an Emergency Temporary Standard, or ETS, to implement this requirement. Unlike the ETS issued earlier in 2021, which only applied to certain healthcare employers, this new ETS is anticipated to apply to all public and private employers with at least 100 employees nationwide. The White House estimates that it “will impact over 80 million workers in private sector businesses.” Calling on entertainment venues to require proof of vaccination or testing for entry. and to impose mandatory weekly testing requirements for any employees that remain unvaccinated. The Administration is directing the Occupational The Administration’s plan calls upon sports arenas, concert halls, and other large venues to require patrons to be vaccinated or show proof of a negative test for entry. However, the White House has not indicated that any regulations will be adopted compelling such big venues to impose vaccination and testing requirements for entry. Requiring all employers with 100 or more employees to provide paid time off to get vaccinated. In connection with the above-mentioned ETS, OSHA will adopt a rule requiring that employers with more than 100 employees provide paid time off for employees to get vaccinated and to recover from any vaccination side effects. Requiring all federal workers to be vaccinated. A new executive order will eliminate the exception established in July, which allowed federal workers to remain unvaccinated so long as they satisfied weekly testing and other safety requirements. Going forward, vaccination will be mandatory for covered federal employees. Imposing mandatory vaccination requirements for workers employed by health care facilities. The Centers for Medicare & Medicaid Services will adopt regulations requiring COVID-19 vaccination for workers “in most health care settings that receive Medicare or Medicaid reimbursement, including but not limited to hospitals, dialysis facilities, ambulatory surgical settings, and home health agencies.” It is estimated that these requirements will apply to approximately 50,000 providers and cover most health care workers nationwide. TRUSTED NATIONWIDE NO MORE BARRIERS. NO MORE INCONVENIENCES. ANSWERS WHEN AND WHERE YOU NEED THEM iOpen is being provided to 10,500,000 Students attending Universities & Colleges across the country HOW IT WORKS iOpen offers COVID-free campuses with speed, simplicity, affordability, access and reliability. No more lines, no more wait times, no more barriers and no more inconveniences. The answer is now in your hands on how to manage campuses safely and inexpensively. IOPEN DROP SHIPS AN INDICAID COVID-19 TEST TO THE IOPEN APP USER AT THE PRICE OF $4.80. ON-DEMAND THE USER CONNECTS WITH AN IOPEN MEDICAL TECHNICIAN VIA VIDEO CHAT. THE TEST IS ADMINISTRATED AND THE RESULTS ARE IMMEDIATELY UPLOADED. GET PEACE OF MIND NOW For Added Security Orders are Taken by Phone – An iOpen Representative Will Return a Call for Your Request Please enable JavaScript in your browser to complete this form. Name * First Last Email * Phone Number * How many FDA Approved Tests do you need? Selected Value: 2 Submit STAY INFORMED Sign up for our newsletter to get the latest updates, thoughts, and ideas from iOpen. Please enable JavaScript in your browser to complete this form. Email * Submit *Please refer to our Privacy Policy for more details. -------------------------------------------------------------------------------- COMPANY * About Us * Contact us * Leadership * In the News * Careers * Physicians MEMBER BENEFITS * Telemedicine * Test Kits MEMBER SOLUTIONS * MyTelemedicine * Access a Doctor * Zeally Health * Golexi – Pet Telehealth * Careers -------------------------------------------------------------------------------- © 2022 iOpen, inc * * * 202-792-8022 support@www.iopenworld.com Copyright iOpen© 2023 "*" indicates required fields Please, Fill out the entire form. Step 1 of 5 20% REQUEST AT-HOME TESTS Insurers cover up to 8 at-home COVID-19 tests per person monthly. All fields are required. Do you carry health insurance?* Yes No Note: This program only applies to those persons who carry health insurance Do you want express of ground shipping?* UPS Ground (7-10 Days) FREE Express shipping & handling 2-3 day - $29.99 Note: If you order less than 8 kits shipping charges apply. Tests 8 Tests2 Tests4 Tests6 Tests Minimum order of 2 tests. You will receive 2 tests per pack. Anything less than 8 tests will have a shipping charge applied. WHO ARE THE TESTS FOR? Insurers cover up to 8 at-home COVID-19 tests per person monthly. All fields are required. Are you submitting the request for yourself of someone else?* Myself Someone else Reason for Testing* e.g. high-risk settings, possible symptoms, large gatherings with possible exposure. Address Recognized by your Insurance Company* First Name and Last on record with your Insurance Company must match exactly. First Name Last Name Date of birth* MM slash DD slash YYYY Address* Street Address Unit, apartment etc (optional) City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code This is the address that your insurance company has on record for you. Could be your address or possibly your spouse/parent's address. Email address* Mobile Number* PREVIEW SUBMISSION Do you carry health insurance? Do you want express of ground shipping? Tests Are you submitting the request for yourself of someone else? Reason for Testing First Name Last Name Date of birth (MM/DD/YYYY) Address , , Email address Mobile Number Sex assigned at birth* Female Male Note: Required fields* Insurance Carrier* AetnaCignaHumanaUnitedBlue Cross Blue ShieldMutual of OmahaTRUSTMARKOther Insurance Number* Insurance Group Number *If applicable Shipping Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PREVIEW SUBMISSION Do you carry health insurance? Do you wont express of ground shipping? Tests Are you submitting the request for yourself of someone else? Reason for Testing First Name Last Name Date of birth (MM/DD/YYYY) Address , , Email address Mobile Number Sex assigned at birth Insurance Carrier Insurance Number Insurance Group Number Shipping Address , , Add your insurance card image* Accepted file types: jpg, jpeg, png, hvec, Max. file size: 256 MB. PREVIEW SUBMISSION Do you carry health insurance? Do you wont express of ground shipping? Tests Are you submitting the request for yourself of someone else? Reason for Testing First Name Last Name Date of birth (MM/DD/YYYY) Sex assigned at birth Insurance Carrier Insurance Number Insurance Group Number Address , , Email address Mobile Number Shipping Address , , Your Insurance Card Consent* I agree to the privacy policy. SENT! We just sent you a link to download the app. OK Notifications