Antibody Appointment Request

COVID-19 ANTIBODY

APPOINTMENT REQUEST

To request an appointment, please complete and submit this form.

If you need further assistance, please call us at 626-584-1200.

1250 East Green Street • Pasadena • CA • 91106

www.healthytraveler.com
*ANTIBODY TEST DOES NOT DETECT IF YOU
CURRENTLY HAVE AN ACTIVE COVID-19 VIRUS*

The antibody test is to determine
previous exposure to COVID-19.

If you are traveling, this test may not qualify as proof for entry. Please confirm with your arrival or departure agency.

UPON COMPLETION OF YOUR ANTIBODY TEST, A CERTIFIED LETTER WILL BE PROVIDED WITH YOUR TEST RESULTS.
OUR CLINIC IS OPEN BY APPOINTMENT ONLY

• PROPER FACE MASK IS REQUIRED PRIOR TO ENTRY

• TEMPORAL TEMPERATURE CHECK WILL BE TAKEN PRIOR TO SERVICE

• ENTRY FOR PATIENTS ONLY. No guests or companions are allowed with you.

If you have any concerns, please call or text directly:

626-584-1200

Text 626-344-7544

All calls and texts are monitored 24/7 and we respond on a timely basis.
** Information About Insurance Billing**

The majority of individuals can have COVID-19 PCR testing performed at their primary care physician's clinic. An alternative option is for individuals to have antibody testing performed at the Healthy Traveler Clinic. This option for testing by Healthy Traveler Clinic is solely your financial responsibility.

Healthy Traveler Clinic is not a member of any insurance network. Therefore, we cannot provide you with a receipt containing the necessary information required for submission to your insurance carrier.

COVID-19 ANTIBODY TEST FEE $95
I would like to schedule an appointment for *

COVID-19 Antibody Rapid Test - SARS CoV-2 Antibody Test IgM & IgG
Date of Travel/Departure

Month Day Year
Date
Are you? *

New Patient Returning Patient- last visit less than 12 months ago. Returning Patient- last visit more than 12 months ago. Minor under 18 Age 64+
Full Name *

First Name Last Name
E-mail *
Your Cellular Mobile & Text Phone Number *

Area Code Phone Number
Secondary Contact Phone Number

Area Code Phone Number
Type of Alternate phone number above?

Mobile Cellphone Home Office
Preferred Appointment Scheduling (check boxes) *

Morning Appointment Afternoon Appointment Tuesday Wednesday Thursday
HEALTHY TRAVELER WILL NOTIFY YOU OF OUR EARLIEST AVAILABLE APPOINTMENT EITHER BY EMAIL OR TEXT.

Availability of appointments is extremely limited during this time in compliance with LA County Department of Health and COVID-19.
Number of Patients Requesting Appointments *
Additional Name for Appointment

First Name Last Name
Additional Name for Appointment

First Name Last Name
Additional Name for Appointment

First Name Last Name
Additional Message to Clinic:
CONSENT FOR THIS ANTIBODY TEST.

I am requesting for Healthy Traveler Clinic to administer the COVID-19 Antibody test also known as SARS CoV-2 Antibody Test IgM & IgG.

ANTIBODY TEST which looks for the presence of COVID-19 antibodies which are the body’s immune system response to viral infection. These antibodies usually don’t appear until a few days after infection.

THIS TEST DOES NOT TELL YOU IF YOU HAVE AN ACTIVE COVID-19 INFECTION.

The majority of individuals can have COVID-19 PCR testing performed at their primary care physician's clinic. An alternative option is for individuals to have antibody testing performed at the Healthy Traveler Clinic. This option for testing by Healthy Traveler Clinic is solely your financial responsibility.

Healthy Traveler Clinic is not a member of any insurance network. Therefore, we cannot provide you with a receipt containing the necessary information required for submission to your insurance carrier.
YOUR CONSENT IS REQUIRED *

I have read the consent above. I completely understand the type of test being administered. I would like to schedule an appointment.
Referral to Healthy Traveler Clinic by:

Returning Patient Referral from Physician Referral from Friends/Family Read Article about Healthy Traveler Centers for Disease Control Website Google Search Engine Yahoo Search Engine Bing Search Engine Facebook Twitter Advertising
Copyright MMXVIII. Healthy Traveler® is a registered trademark with the United States Patent and Trademark Office and Canadian Office of Intellectual Properties. No whole or partial reproduction of this website including printed or electronic is allowed without written permission from Healthy Traveler. All Rights Reserved.
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