COVID-19 SURVEILLENCE TESTING

COVID-19 SURVEILLENCE TESTING

Includes all non-medically necessary testing e.g. travel testing, routine workplace testing, routine school testing, testing to attend an event, etc.
Patient Demographics

Fill out Info for Each Patient - Separate Form Required For Each Family Member
Name *

First Name Last Name
Date of Birth: *

Month Day Year
Date
Gender: *

M F
Address *

Address

Street Address Line 2

City/State/Zipcode
Phone #: *
Email Address: *
example@example.com
Consent Release: I, the undersigned, understand and grant permission to Clear Molecular and its affiliates to process my specimen for laboratory services provided. I understand that services provided may not be covered by my insurance. I hereby authorize the ordering physician and/or clinic to disclose any personal or medical information that may be needed to process my testing and services rendered by Clear Molecular LLC and its affiliates. I understand that my records may be protected under 42 CFR Part 2, under which I may revoke my consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires six (6) months after the date of program discharge. I understand that IndyCare Medical North Carolina is providing specimen collection services only and does not provide laboratory analysis of the collected specimen and agree to hold IndyCare Medical North Carolina harmless for any delays in the processing of the specimen or reporting of results by the reference laboratories.
How Will You Be Paying?

CASH at clinic -{please call (919)245-1213 to schedule} Credit Card

PLEASE CHECK AND FILL OUT PAYMENT INFORMATION *

COVID-19 PCR TEST (MON - THU) NEXT EVENING RESULTS

$ 139.00

COVID-19 PCR TEST (FRIDAYS) RESULTS IN 2 DAYS

$ 139.00

COVID-19 PCR TEST (SATURDAY) RESULTS IN 2-3 DAYS

$ 139.00

RAPID ANTIGEN TEST Note: We will provide the rapid antigen test results on a form singed by our medical provider that includes details of the test performed, the results, our practice contact details and our laboratory certification number.

$ 100.00

Total

$ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Patient Signature: *

Clear
Schedule Your Testing Day/Time *

COVID-19 SURVEILLENCE TESTING

Patient Demographics