COVID 19 Self Assessment Questionnaire

COVID19 Appointment Request Questionnaire

Test Times: Monday - Friday: 09:00 am to 3:00 pm
Appointment (Please make note of the DATE you are signing up for) *
Legal Name (no nicknames) *

First Name Last Name
Date of Birth *
Sex *
Phone Number *
Age *
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Reason for Testing *

Symptoms Exposure or Potential Exposure Event Pre-Travel Testing General Screening Work Requirement School or Daycare Requirement Pre Op Requirement Positive At-Home Test
I am interested in the "Test to Treat" program for Paxlovid if I test positive for COVID-19

Yes No
NOTICE:

Prices are subject to change according to funding from the Minnesota Department of Health. We cannot guarantee that you will be notified before the day of your test.
Which COVID test is Required? (To help conserve our stock of PCR tests, if a PCR is not required for your situation, we ask that you consider a Molecular NAAT test or Antigen test.) *

Rapid COVID-19 Antigen test (Results in 30 minutes, Insurance accepted, $40 without insurance) Rapid COVID-19 Molecular NAAT test (results in 30 minutes, $185 - insurance not accepted) Rapid COVID-19 RT-PCR test (results in 1-3 hours $240 - insurance not accepted
Please upload a picture of your insurance card here (antigen tests only):

Browse Files

Cancel of
Which COVID test is Required? *

Rapid COVID-19 Antigen test (Results in 15 minutes, no cost) Rapid COVID-19 Molecular NAAT test (results in 30 minutes, no cost)
Have you been vaccinated for COVID-19? *

Yes No
Which one?
First Dose

Month Day Year
Date
Second dose if applicable

Month Day Year
Date
1. Are you experiencing any of the following:
- Fevers, chills, body aches
- Difficulty breathing
- Cough
- Sore Throat
- Runny Nose
- Loss of taste or smell
*

YES NO
Within the last 14 days, Have you traveled internationally? *

YES NO
If yes, where?
In the past 14 days, have you had known exposure to someone with COVID-19? *

YES NO
Are you a healthcare worker? *

YES NO
By signing below, I understand that I am receiving a COVID-19 test and that it is ultimately my responsibility to select the correct test for my situation. If I am in need of a specific type of documentation, such as an official electronic copy or paper document with a raised seal, it is my responsibility to communicate this to the Minneapolis Health Clinic PLLC staff at the time of my appointment. If my insurance information is required for the test, I understand that it is my responsibility to bring this information with me at the time of my appointment, and I will be charged for the test if I do not bring the proper insurance information. If there is a fee for this test, I understand that I am financially responsible for this at the time of my appointment, and Minneapolis Health Clinic is not responsible for any insurance reimbursement issues or denied claims if I attempt to submit a claim or the receipt to my insurance company *

Clear
Parent or Guardian Name (if under 18 or the patient is unable to sign)

First Name Last Name
Please sign below if you would like to allow a third-party to receive your results on your behalf

Clear
Click "next" to read instructions for your appointment.

COVID Testing Appointment Policies
(Please read carefully... your appointment isn't scheduled yet!)

There is a 10 minute late policy for all patients.
Please call us immediately if you are going to be late.
Minneapolis Health Clinic reserves the right to deny testing if you arrive more than 10 minutes late for your appointment - the final decision is non-negotiable.

If you need to cancel, call our office so we can offer this spot to someone else. You may still get an appointment reminder from our system on the day of your cancelled appointment.

Please check your junk mail if you do not see a confirmation email. If you do not receive anything, call us right away!

To keep all of our patients healthy, we keep our waiting room capacity as low as possible. Please call our office at (763)496-5708 from your vehicle when you arrive for further instructions.
Please do not enter the building without prior approval from our staff.

Test results:
All COVID tests are guaranteed to be completed same-day. If there is an issue with your test results, or you haven't received your test results by 3:45 pm on the day of your appointment, please contact our clinic - we do not have staff available after business hours to help with results and travel documents.

Minneapolis Health Clinic, PLLC
4825 Olson Memorial Hwy
Golden Valley, MN 55422
Phone: (763)496-5708

We look forward to seeing you!

Please be kind to our staff! Minneapolis Health Clinic PLLC has a zero-tolerance harassment policy. If a patient is found to be violating this policy, clinic staff reserve the right to refuse service.
I have read the above information, and I agree to the appointment policies *

I agree to the appointment policies
Should be Empty:

COVID19 Appointment Request Questionnaire