COVID-19 TRAVEL TESTING

COVID-19 TRAVEL TESTING
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/Insurance Release: I, the undersigned, understand and grant permission to Radeas Laboratories, LLC to process my saliva sample for laboratory services provided. I understand that services provided may not be covered by my insurance. I further understand that I may be responsible for co-pays, deductibles, and any amount not covered by my insurer. By signing below, I acknowledge that payment may be shared with IndyCare Hillsborough and Radeas Laboratories, LLC. I hereby authorize the ordering physician and/or clinic to disclose any personal or medical information that may be needed to process claims related to services rendered by Mako Medical Laboratories, 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.
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 (Saliva) (Mon - Thu) NEXT EVENING RESULTS

$ 139.00

COVID-19 PCR TEST (Nasal Swab) (Fri & Sat )RESULTS IN 2-3 DAYS

$ 139.00

EXPEDITED SERVICE - SAME DAY RESULT Choose the PCR Saliva test above and then select this option. Only available for Saliva Testing, Mon - Fri from 11:00AM - 11:30AM .

$ 100.00

RAPID ANTIGEN TEST Note: Some travel destinations now also require a rapid antigen test on the day of departure. This is IN ADDITION TO the PCR test within 72hrs of departure. Most destinations will not accept a rapid antigen test alone.

$ 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 TRAVEL TESTING

Patient Demographics