COVID-19 Antibody Test Request

COVID-19 Rapid Test Request

Same Day Results
Test Location:

2500 Metro Centre Blvd Ste7-8 West Palm Beach FL 33407
Testing is by appointment only utilizing a secured back office door, which is a separate private office not inside the main building. Contact us by phone or text at 1-800-409-3804 if further assistance is required for filling out this form. Please absolutely no walk-ins. Application fonts may appear different on certain smartphones, it is recommended to fill out this form on a desktop or laptop computer, however, submissions still can be made through smartphones through this secured form. Mask or facial covering and identification are required during the appointment.

Attention: If you are uninsured and cannot afford to pay for a Covid-19 Rapid test, please contact 1-800-409-3804 to find out what options in the community are available prior to filling out and submitting this form.
Section 1- Demographic Information
Name *

First Name Last Name
Date of Birth *

Month Day Year
Must be 18 years or older
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Government ID (Upload is optional, but identification is required onsite)
How Would You Like To Receive Your Results?

Email (password protected) Mail Wait( Must Wait In Vehicle) Secured Portal
Section 2- Primary Care Physician or Medical Group Information

This field is optional but vital in our contact tracing plan of care as it allows us to communicate with your provider the same day tested during regular business hours. If you do not have a primary care provider or do not want your information released to your primary care physician skip this section and move on to Section 3. Health Information.
Provider Name / Practice Name
Practice Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Practice Phone Number

Area Code Phone Number
Practice Fax Number

Area Code Fax Number
Section 3- Health Information

1) Have you had any of the following symptoms in the last 24 hours? *

	Yes	No
Cough
Shortness of breath / difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours: *

	Yes	No
Fever (100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

If you answered “Yes” to at least 3 questions above, we suggest that you DO NOT proceed with the request and seek medical attention and follow CDC guidelines. In addition to seeking out medical advice from your primary care, You may also want to follow the methods listed below:
- Self- quarantine for at least 10 days from the date on which you first experienced any of the above symptoms ; AND
- Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
- Improved respiratory symptoms (no cough, shortness of breath)

2) In the last 7 days have you: *

	Yes	No
tested positive for Covid-19 by a molecular (PCR) test

3) In the last 10 days have you experianced: *

	Yes	No
Loss of smell or taste?
Shortness of breath, weakness or lethargy?
Lightheadedness or dizziness
Vomiting or diarrhea, slurred speech or seizure?

4) In the last 14 days have you: *

	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms ?
Traveled internationally or taken a cruise

Section 4- Appointment Scheduling & Waiver

Please schedule a time that is convenient for you, if time requested not available please contact 1-800-409-3804 during normal business hours to see if accommodation may be available.
Request appointment *
I certify to the best of my knowledge; this information is accurate. By signing below I expressly agree to release and discharge World Wide Health Services and all of its affiliates, staff, members, attorneys, agents, heirs, volunteers, representatives, predecessors, successors, assigns, from any and all claims or causes of action and I agree to voluntarily give up or waive any right that I otherwise have to bring legal action against World Wide Health Services and all of its affiliates, staff, members, attorneys, agents, heirs, volunteers, representatives, predecessors, successors, assigns for any professional, general, personal injury, property damage and or any type of injury, claim or legal action not mentioned. I waive any and all liabilities towards, or against World Wide Health Services, its staff, affiliates as the VOLUNTARILY Covid-19 testing is at my will and at my risk and World Wide Health Services holds no liabilities. Furthermore, I understand that all payments made to World Wide Health Services are final, no refunds will be provided. I understand that I have 24 hours prior to my appointment to reschedule my appointment, anything after 24hours will be subjected to an additional $30 rescheduling fee. I also understand that World Wide Health Services is not a medical provider such as a doctor, although a doctor is not required for this type of testing, all test conducted is at my will, and at my risk. I agree to seek medical attention and advice from my primary care provider or clinic if needed and if my test results come back positive for Covid-19 or if I have a negative test but am currently experiencing any Covid-19 symptoms. I agree to follow all CDC and health care guidelines that are made publicly available. For any reason should my results come back positive, I understand that World Wide Health Service may be subject to report all test results to the appropriate state agency or my primary care if listed, I agree for them to release any and all sensitive information to the required agency and or listed primary care health care practice. Other than that all information will be kept private and confidential.
Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date
Section 5- Confirm Request, Agree to Terms & Payment Submission
Total due(ON-SITE): $65.00

Total due is the total fee required for Covid-19 CLIA waived rapid test which can be paid on-site. By clicking "Submit", you indicate that you, as the testing request individual or legal guardian of the testing request individual, agree:
1. to follow up with my regular medical provider for ongoing care;
2. to the best of my knowledge, all information submitted is accurate;
3. to the Terms of Service and Consent to Telehealth.
4. I understand that the total due now is the complete cost of my Voluntarily CLIA waived Covid-19 rapid test and that all purchases are final.
Should be Empty:

COVID-19 Rapid Test Request

Test Location:

Section 1- Demographic Information

Section 2- Primary Care Physician or Medical Group Information

Section 3- Health Information

Section 4- Appointment Scheduling & Waiver

Section 5- Confirm Request, Agree to Terms & Payment Submission