COVID-19 Patient Screening Disclosure Form

COVID 19 | Patient Registration

For any questions regarding the registration form please contact our Client Services team at: (704) 716-7837
The standard turnaround time is 24-36 hours.

URGENT (STAT) turnaround time is 24 hours, guaranteed.

You may not have out-of-pocket costs if using insurance or if you are eligible for no-cost testing according to federal or state guidelines. You should contact your insurer to confirm coverage before scheduling a test. You may be responsible for the full price of the test ($149.99) if you do not meet the criteria established by your insurer.
Patient Demographic Information
Full Name *
Date of Birth *

Month Day Year
Date
Gender *
Ethnicity *
Race *
Mobile Phone # *
Positive result notification: *

In case of a Positive result, I authorize the laboratory to contact me at the number listed above. In case of a Positive result, please contact an alternate number, listed below.
Alternate Phone #
Alternate Phone #
Email Address *
Laboratory result email notification: *

I authorize the laboratory to email a copy of my lab report to the email listed above. I authorize the laboratory to email a copy of my lab report to an alternate email address listed below.
Alternate Email Address
Alternate Email Address
Would you like us to send a copy of your lab results to your primary physician?

Yes No
Primary Physician Name
Office/Facility Name
Office/Facility Fax Number
Patient Address
Patient Address *

Street Address

Street Address Line 2

City State

Zip Code
Appointment Information
Appointment Date *
Vehicle Make and Model *
Vehicle Color *
URGENT?

YES NO
Patient Required Screening Questions

*Required by the State Health Department.
Do you have symptoms (fever, chills, cough, shortness of breath, etc)? *

Yes No
When did the symptoms begin?

Month Day Year
Date
Is this your first COVID-19 test? *

Yes No
Are you employed in a healthcare environment with patient exposure? *

Yes No
Have you been hospitalized for COVID-19? *

Yes No
Have you been admitted to an ICU for COVID-19? *

Yes No
Are you pregnant? *

Yes No
Are you a Congregate Care/Nursing Home Resident? *

Yes No
Signature: By signing below, you acknowledge that the answers you provided are true and accurate to the best of your knowledge. (Please use your mouse to sign if you are using a desktop or laptop.) *

Clear
Billing Options *

I have an active insurance I do not have insurance
INSURANCE CARD - FRONT
INSURANCE CARD - BACK
Insurance Company Name:
Insurance Policy Number:
Insurance Group Number (if applicable):
DRIVER LICENSE OR VALID STATE ID
ADDITIONAL SERVICES
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OPTIONAL STAT (URGENT) TESTING $ 100.00
24-Hour Turnaround Time Guaranteed. Suitable for Travel Testing Guidelines. Your specimen will be prioritized and completed within 24 hours!

Total $ 0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

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COVID 19 | Patient Registration

Patient Demographic Information

Patient Address

Appointment Information

Patient Required Screening Questions